| NPI | 1164403911 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: SD LPC998) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: SD LPCMH2105) |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2007-07-08 |