| NPI | 1396976890 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: MD LC2930) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MD LCPC2930) |
| Enumeration Date | 2009-07-31 |
| Last Update Date | 2025-09-23 |