| NPI | 1124686290 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: WA LH60938568) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: WA LH60938568) |
| Enumeration Date | 2019-06-03 |
| Last Update Date | 2019-06-03 |