| NPI | 1194825745 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: ME LC6134) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: ME LC6134) |
| Enumeration Date | 2006-09-24 |
| Last Update Date | 2015-01-23 |