| NPI | 1659004604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: PA APC000863) |
| Additional Taxonomies | 261QM0855X Clinic/Center, Adolescent and Children Mental Health |
| Enumeration Date | 2022-07-07 |
| Last Update Date | 2025-07-29 |