| NPI | 1235694308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MD LC10198) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MD ATC251) |
| Enumeration Date | 2019-02-04 |
| Last Update Date | 2020-12-31 |