| NPI | 1639040397 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 261QM0850X Clinic/Center, Adult Mental Health |
| 101YM0800X Counselor, Mental Health | |
| 261QM0855X Clinic/Center, Adolescent and Children Mental Health | |
| Enumeration Date | 2025-09-16 |
| Last Update Date | 2025-09-16 |