| NPI | 1245763564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: VA 0701010409) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MD LC9461) |
| 101YM0800X Counselor Mental Health (Licence: OH C.1300386) | |
| Enumeration Date | 2017-04-04 |
| Last Update Date | 2024-02-22 |