| NPI | 1023536216 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TH0100X Psychologist, Health Service (Licence: 6301019844) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MI 6401019160) |
| Enumeration Date | 2017-09-07 |
| Last Update Date | 2026-08-11 |