| NPI | 1427824630 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: WV 2916) |
| Additional Taxonomies | 103TE1100X Psychologist Exercise & Sports (Licence: 1134) |
| Enumeration Date | 2023-11-29 |
| Last Update Date | 2023-11-29 |