| NPI | 1700559192 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: CA 12611) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| 101YP2500X Counselor, Professional (Licence: CA 12611) | |
| Enumeration Date | 2021-07-30 |
| Last Update Date | 2026-10-05 |