| NPI | 1609572874 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: NC A21439) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NC 1733988) |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2023-01-31 |
| Last Update Date | 2025-10-12 |