| NPI | 1407390925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: MT BBH-LCPC-LIC-44183) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 101YM0800X Counselor, Mental Health (Licence: WY LPC-2225) | |
| Enumeration Date | 2016-12-19 |
| Last Update Date | 2025-12-08 |