| NPI | 1184193104 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: PR 05200262) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: PR 05200262) |
| Enumeration Date | 2018-11-20 |
| Last Update Date | 2018-11-20 |