| NPI | 1790070878 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: SC 8858) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: WY LPC1256) |
| Enumeration Date | 2011-06-16 |
| Last Update Date | 2023-06-13 |