| NPI | 1891210910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 101YS0200X Counselor, School |
| 171W00000X Contractor | |
| 252Y00000X Early Intervention Provider Agency | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-08-09 |
| Last Update Date | 2022-07-21 |