| NPI | 1700508462 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: TX 99421) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2022-09-19 |
| Last Update Date | 2026-03-24 |