| NPI | 1104265370 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: CO PSY.5348) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: CO NLC.0103759) |
| 101YP2500X Counselor, Professional (Licence: CO LPC.0013973) | |
| Enumeration Date | 2013-06-20 |
| Last Update Date | 2023-02-16 |