| NPI | 1053832642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810008128) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| Enumeration Date | 2017-07-04 |
| Last Update Date | 2025-08-15 |