| NPI | 1790034486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: ND 5222) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: ME MC14322) |
| Enumeration Date | 2012-09-10 |
| Last Update Date | 2022-01-26 |