| NPI | 1952646903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: WA LW60951940) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: SW124649) |
| Enumeration Date | 2012-12-03 |
| Last Update Date | 2022-09-08 |