| NPI | 1760138739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101Y00000X Counselor (Licence: ME CC7411) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MA LMHC10004628) |
| Enumeration Date | 2022-02-28 |
| Last Update Date | 2025-08-20 |