| NPI | 1912558123 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YA0400X Counselor Addiction (Substance Use Disorder) | |
| 103TB0200X Psychologist Cognitive & Behavioral | |
| Enumeration Date | 2019-09-28 |
| Last Update Date | 2023-07-11 |