| NPI | 1922680057 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: OR R10305) |
| Additional Taxonomies | 106S00000X Behavior Technician |
| Enumeration Date | 2021-04-27 |
| Last Update Date | 2026-03-23 |