| NPI | 1043878507 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA 11039) |
| Enumeration Date | 2019-05-30 |
| Last Update Date | 2020-08-19 |