| NPI | 1538884747 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: OR C10195) | 
| Additional Taxonomies | 101Y00000X Counselor (Licence: ID 8857) | 
| Enumeration Date | 2022-10-10 | 
| Last Update Date | 2025-07-15 |