| NPI | 1891760930 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: IA 00124) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MO 2026030338) |
| Enumeration Date | 2006-02-22 |
| Last Update Date | 2026-07-03 |