| NPI | 1760624795 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: WY 1247) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WY 982) |
| Enumeration Date | 2009-04-06 |
| Last Update Date | 2012-05-29 |