| NPI | 1720816390 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: VA 0904017141) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: VA 0904017141) |
| Enumeration Date | 2024-07-24 |
| Last Update Date | 2026-06-25 |