| NPI | 1700282571 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MT 38241) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: SD SD3348) |
| Enumeration Date | 2014-11-06 |
| Last Update Date | 2019-06-25 |