| NPI | 1073596045 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 2143) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: MA 559) |
| 106H00000X Marriage & Family Therapist (Licence: MA 245) | |
| Enumeration Date | 2005-11-23 |
| Last Update Date | 2016-04-18 |