| NPI | 1104214154 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 101471) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: IA 076371) |
| Enumeration Date | 2014-12-29 |
| Last Update Date | 2021-05-18 |