| NPI | 1306153648 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-10919) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NC 8593) |
| Enumeration Date | 2010-09-08 |
| Last Update Date | 2026-01-16 |