| NPI | 1770613739 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 167G00000X Licensed Psychiatric Technician (Licence: CA PT 17702) | 
| Additional Taxonomies | 101YM0800X Counselor, Mental Health | 
| Enumeration Date | 2007-03-07 | 
| Last Update Date | 2025-09-11 |