| NPI | 1104258318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: ID PSY-202920) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: ID LPC - 5380) |
| Enumeration Date | 2013-07-30 |
| Last Update Date | 2016-05-02 |