| NPI | 1467119701 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 171000000X Military Health Care Provider |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: CO LPCC.0018595) |
| Enumeration Date | 2021-11-22 |
| Last Update Date | 2026-08-04 |