| NPI | 1679761175 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: CA 5327) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: KS 1037) |
| Enumeration Date | 2007-10-09 |
| Last Update Date | 2021-08-30 |