| NPI | 1750830303 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: VT 089.0134396) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2016-09-23 |
| Last Update Date | 2025-04-29 |