| NPI | 1639718729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: OR L16541) |
| Enumeration Date | 2020-01-06 |
| Last Update Date | 2025-10-30 |