| NPI | 1114063740 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: WV 1723) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WV 1723) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2016-08-11 |