| NPI | 1811019789 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: VA 0701004316) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MD LC1116) |
| Enumeration Date | 2007-04-04 |
| Last Update Date | 2008-01-28 |