| NPI | 1104964097 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: VA 0701003573) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: VA 0710102025) |
| Enumeration Date | 2007-02-02 |
| Last Update Date | 2007-07-08 |