| NPI | 1669871729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: AZ LPC5937T) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MD LGP5777) |
| Enumeration Date | 2014-08-14 |
| Last Update Date | 2018-06-27 |