| NPI | 1366199564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: MT BBH-SWLM-LIC-50378) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2022-03-07 |
| Last Update Date | 2025-07-02 |