| NPI | 1396877957 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: MO 2012022193) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: WI 3860-125) |
| 101YP2500X Counselor Professional (Licence: IL 180006515) | |
| Enumeration Date | 2007-03-09 |
| Last Update Date | 2012-07-05 |