| NPI | 1245697580 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WI 12040-123) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: WI 129286-121) |
| Enumeration Date | 2016-01-18 |
| Last Update Date | 2026-01-15 |