| NPI | 1124635891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: PA PS019120) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: PA PS019120) |
| 103TP2701X Psychologist Group Psychotherapy (Licence: PA PS019120) | |
| Enumeration Date | 2020-09-28 |
| Last Update Date | 2021-07-27 |