| NPI | 1164409777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CO 5334) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: TX 19263) |
| Enumeration Date | 2005-12-23 |
| Last Update Date | 2012-12-18 |