| NPI | 1053598987 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: VA 0810004447) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MO 2006028786) |
| Enumeration Date | 2008-01-22 |
| Last Update Date | 2013-02-20 |