| NPI | 1700594710 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: KY 266685) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KY 266685) |
| Enumeration Date | 2022-11-08 |
| Last Update Date | 2023-08-17 |