| NPI | 1255753216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: KY 252249) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: KY 127148) |
| Enumeration Date | 2014-01-10 |
| Last Update Date | 2019-09-09 |