| NPI | 1164198693 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MI 6451022424) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: OH C.2103322-TRNE) |
| Enumeration Date | 2021-08-16 |
| Last Update Date | 2025-01-06 |