| NPI | 1972019859 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: GA APC006219) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: ID LCPC-10514) |
| 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) (Licence: UT 11412282-6004) | |
| Enumeration Date | 2017-12-14 |
| Last Update Date | 2024-06-04 |