| NPI | 1104380542 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MD LC13221) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MD LGP8781) |
| Enumeration Date | 2019-01-30 |
| Last Update Date | 2022-11-16 |