| NPI | 1619499324 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: OR L18627) |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YM0800X Counselor, Mental Health | |
| Enumeration Date | 2017-07-13 |
| Last Update Date | 2026-08-20 |