| NPI | 1003237090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NE 911) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MO 2013043796) |
| Enumeration Date | 2013-12-18 |
| Last Update Date | 2016-11-29 |