| NPI | 1124740642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: OR L17404) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2022-09-12 |
| Last Update Date | 2026-03-10 |