| NPI | 1679114136 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: 11488-123) |
| Additional Taxonomies | 101YP2500X Counselor Professional |
| 1041C0700X Social Worker Clinical (Licence: WI 11469-123) | |
| Enumeration Date | 2019-10-04 |
| Last Update Date | 2023-12-15 |