| NPI | 1548478365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WI 1530) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WI 663) |
| Enumeration Date | 2007-05-18 |
| Last Update Date | 2025-09-11 |