| NPI | 1053717884 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: AZ PSY-005020) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: AK PCOP892) |
| Enumeration Date | 2014-11-05 |
| Last Update Date | 2022-10-06 |