| NPI | 1063863629 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MS 641183) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: IL 180013378) |
| Enumeration Date | 2016-06-24 |
| Last Update Date | 2026-07-28 |