| NPI | 1912414467 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: FL 21461) |
| Additional Taxonomies | 106S00000X Behavior Technician (Licence: CO 1745556) |
| Enumeration Date | 2018-01-05 |
| Last Update Date | 2021-08-19 |