| NPI | 1912380635 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: MO 2017039593) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MO 2015021261) |
| Enumeration Date | 2015-06-30 |
| Last Update Date | 2017-12-06 |