| NPI | 1689687311 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: MO 2001018628) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MO 2001018628) |
| 101YP2500X Counselor, Professional (Licence: MO 2001018628) | |
| Enumeration Date | 2006-08-14 |
| Last Update Date | 2007-07-08 |