| NPI | 1093292120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: CO 0009925442) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2018-07-21 |
| Last Update Date | 2024-10-02 |