| NPI | 1265557763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0701005107) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: OH E4312) |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2012-04-08 |