| NPI | 1124636030 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: AZ LPC-19411) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: OR C10342) |
| Enumeration Date | 2020-07-16 |
| Last Update Date | 2025-08-11 |