| NPI | 1275151433 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL 1494) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer |
| Enumeration Date | 2020-07-13 |
| Last Update Date | 2025-10-22 |