| NPI | 1215103544 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) (Licence: MD LC4829) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MD LC4829) |
| 101YP2500X Counselor Professional (Licence: MD LC4829) | |
| Enumeration Date | 2008-05-06 |
| Last Update Date | 2023-09-14 |