| NPI | 1104126689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: CO 6129) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: VT 068.0134824TELE) |
| Enumeration Date | 2010-10-29 |
| Last Update Date | 2022-11-07 |