| NPI | 1164840393 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: KY 165928) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: KY LPCPCC00224561) |
| Enumeration Date | 2014-04-04 |
| Last Update Date | 2022-08-30 |