| NPI | 1114655669 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 103T00000X Psychologist |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-08-11 |
| Last Update Date | 2025-08-29 |