| NPI | 1578617429 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: WI 2065) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: WI 833-125) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2012-06-26 |