| NPI | 1235790601 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MD LGP15567) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2019-06-26 |
| Last Update Date | 2024-09-11 |