| NPI | 1760630743 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: WV LPC1900) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: VA 0701007378) |
| Enumeration Date | 2008-09-03 |
| Last Update Date | 2019-05-20 |