| NPI | 1003453903 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities | |
| Enumeration Date | 2019-12-10 |
| Last Update Date | 2020-09-17 |