| NPI | 1902212681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor Professional (Licence: TX 74731) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MS 335881) |
| 225800000X Recreation Therapist (Licence: MS 54965) | |
| 101YP2500X Counselor Professional (Licence: MS 1903) | |
| Enumeration Date | 2014-07-02 |
| Last Update Date | 2015-10-19 |