| NPI | 1609380344 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: AZ LPC-16952) |
| Additional Taxonomies | 251S00000X Community/Behavioral Health (Licence: AZ 16952) |
| Enumeration Date | 2017-11-16 |
| Last Update Date | 2021-02-08 |