| NPI | 1124658356 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WA MC61661558) |
| Additional Taxonomies | 101Y00000X Counselor |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2020-01-15 |
| Last Update Date | 2025-03-17 |