| NPI | 1699207761 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: WA LH61655803) | 
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: TX 73731) | 
| Enumeration Date | 2017-03-29 | 
| Last Update Date | 2025-08-28 |