| NPI | 1861662637 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: GA LPC3930) | 
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: GA lpc003930) | 
| Enumeration Date | 2008-03-07 | 
| Last Update Date | 2011-04-07 |