| NPI | 1104814334 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: GA 812) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: GA 236) |
| Enumeration Date | 2005-10-11 |
| Last Update Date | 2007-07-08 |