| NPI | 1033541115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 246778) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2013-07-31 |
| Last Update Date | 2019-09-06 |