| NPI | 1790714301 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP1600X Counselor Pastoral (Licence: KY 15038) |
| Additional Taxonomies | 2255A2300X Specialist/Technologist Athletic Trainer (Licence: KY 0074) |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2016-02-12 |