| NPI | 1457633935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: CT 009689) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 222Q00000X Developmental Therapist | |
| Enumeration Date | 2011-09-12 |
| Last Update Date | 2017-01-19 |