| NPI | 1154895126 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: OH CDCA.168848) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health |
| Enumeration Date | 2019-01-14 |
| Last Update Date | 2020-02-24 |