| NPI | 1295452365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: IL 180004170) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist, Athletic Trainer (Licence: IL 180004170) |
| Enumeration Date | 2022-10-20 |
| Last Update Date | 2022-10-20 |