| NPI | 1639761414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: FL IMH26269) |
| Additional Taxonomies | 225200000X Physical Therapy Assistant (Licence: FL 29646) |
| Enumeration Date | 2021-02-03 |
| Last Update Date | 2025-06-10 |