| NPI | 1508152562 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KY 167330) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2011-06-28 |
| Last Update Date | 2022-07-21 |