| NPI | 1134158090 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: SC 4714) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: SC 4714) |
| 101YM0800X Counselor, Mental Health (Licence: SC 4714) | |
| Enumeration Date | 2006-07-02 |
| Last Update Date | 2012-02-06 |