| NPI | 1750779054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: NM CCMH0221261) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: NM 0176261) |
| Enumeration Date | 2015-01-08 |
| Last Update Date | 2022-03-15 |