| NPI | 1124505904 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KY 272891) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2018-07-24 |
| Last Update Date | 2022-03-24 |