| NPI | 1831703859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health |
| Additional Taxonomies | 261QC1500X Clinic/Center Community Health |
| 261QF0400X Clinic/Center Federally Qualified Health Center (FQHC) (Licence: MA 4141) | |
| Enumeration Date | 2020-09-08 |
| Last Update Date | 2022-04-07 |