| NPI | 1972121085 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 251S00000X Community/Behavioral Health |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 101YP2500X Counselor, Professional | |
| Enumeration Date | 2020-07-07 |
| Last Update Date | 2020-07-07 |