| NPI | 1720674203 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: KY 258093) |
| Additional Taxonomies | 1041C0700X Social Worker, Clinical (Licence: MN 33578) |
| Enumeration Date | 2020-12-18 |
| Last Update Date | 2026-05-05 |