| NPI | 1922475052 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: OR C4896) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: OR R3449) |
| 251S00000X Community/Behavioral Health (Licence: OR R3449) | |
| Enumeration Date | 2015-08-24 |
| Last Update Date | 2025-04-17 |