| NPI | 1790799419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: IL 180.006978) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MO 2005030089) |
| Enumeration Date | 2006-07-28 |
| Last Update Date | 2008-09-03 |