| NPI | 1104601913 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: HI 5095) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: HI 001084104) |
| Enumeration Date | 2023-08-29 |
| Last Update Date | 2024-11-12 |