| NPI | 1144347667 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YP2500X Counselor, Professional (Licence: GA 62419) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: GA 62419) |
| 171000000X Military Health Care Provider (Licence: GA 62419) | |
| Enumeration Date | 2007-03-22 |
| Last Update Date | 2007-07-08 |