| NPI | 1770564551 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MA 102096) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA 102096) |
| Enumeration Date | 2005-11-09 |
| Last Update Date | 2011-06-15 |