| NPI | 1619953916 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: ID LCPC2990) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: ID LMFT2991) |
| Enumeration Date | 2005-12-19 |
| Last Update Date | 2007-07-08 |