| NPI | 1497378616 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101Y00000X Counselor | 
| Additional Taxonomies | 101Y00000X Counselor (Licence: OH C.2103771) | 
| 101Y00000X Counselor (Licence: OR C7584) | |
| Enumeration Date | 2020-05-21 | 
| Last Update Date | 2025-08-18 |