| NPI | 1902881600 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: IN 39000072A) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: KY KY-0017) |
| Enumeration Date | 2005-12-14 |
| Last Update Date | 2007-07-08 |