| NPI | 1871244244 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: CA 130605) |
| Additional Taxonomies | 261QM0850X Clinic/Center Adult Mental Health (Licence: CA 130605) |
| Enumeration Date | 2022-01-17 |
| Last Update Date | 2022-04-25 |