| NPI | 1104561356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: UT 14063570-3501) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: NC P018045) |
| Enumeration Date | 2022-05-02 |
| Last Update Date | 2024-10-08 |