| NPI | 1407302649 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0801X Clinic/Center Mental Health (Including Community Mental Health Center) |
| Additional Taxonomies | 104100000X Social Worker |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2018-05-25 |