| NPI | 1316132145 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: IA R-12996) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NE 3865) |
| Enumeration Date | 2007-09-14 |
| Last Update Date | 2023-07-24 |