| NPI | 1033730296 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TC1900X Psychologist Counseling |
| 103TB0200X Psychologist Cognitive & Behavioral | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) | |
| Enumeration Date | 2020-04-29 |
| Last Update Date | 2020-04-29 |