| NPI | 1053801316 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: AZ 4959) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: AZ 14311) |
| Enumeration Date | 2018-05-12 |
| Last Update Date | 2020-11-19 |