| NPI | 1659920742 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health |
| Additional Taxonomies | 101Y00000X Counselor |
| 106S00000X Behavior Technician | |
| Enumeration Date | 2019-09-10 |
| Last Update Date | 2022-08-31 |