| NPI | 1770004533 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: KY 165707) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: KY 165707) |
| Enumeration Date | 2017-07-03 |
| Last Update Date | 2025-07-16 |