| NPI | 1639625650 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: OK RBT-19-76312) |
| Enumeration Date | 2016-08-30 |
| Last Update Date | 2022-01-13 |