| NPI | 1164728697 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MS #0640) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: AL #2603) |
| Enumeration Date | 2011-02-01 |
| Last Update Date | 2011-02-01 |