| NPI | 1114565546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: FL MH17587) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: FL MCAP100855) |
| 225700000X Massage Therapist (Licence: FL MA37937) | |
| Enumeration Date | 2019-12-17 |
| Last Update Date | 2023-12-19 |