| NPI | 1902461841 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 104100000X Social Worker (Licence: NY 0458331) |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| Enumeration Date | 2019-05-07 |
| Last Update Date | 2019-05-07 |