| NPI | 1194525626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: AZ LAC-23402) |
| Enumeration Date | 2025-03-14 |
| Last Update Date | 2025-04-16 |