| NPI | 1679297311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MS 10596) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MS 4939) |
| Enumeration Date | 2022-09-27 |
| Last Update Date | 2025-08-12 |