| NPI | 1629600374 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X (Licence: NC 12735) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NC 12735) |
| 101YM0800X Counselor, Mental Health (Licence: NC 12735) | |
| Enumeration Date | 2020-02-11 |
| Last Update Date | 2024-03-26 |