| NPI | 1962049171 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 1041C0700X Social Worker, Clinical (Licence: KY 257831) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: KY 9186) |
| Enumeration Date | 2019-12-06 |
| Last Update Date | 2023-04-20 |