| NPI | 1134767437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MA 123358) |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health (Licence: MA 223187) |
| Enumeration Date | 2019-12-17 |
| Last Update Date | 2024-06-12 |