| NPI | 1164946638 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent |
| 104100000X Social Worker | |
| 1041C0700X Social Worker, Clinical | |
| 167G00000X Licensed Psychiatric Technician | |
| Enumeration Date | 2017-07-27 |
| Last Update Date | 2022-07-21 |