| NPI | 1124554555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 00444) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: IA 00444) |
| Enumeration Date | 2017-05-04 |
| Last Update Date | 2019-07-31 |