| NPI | 1164606570 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: SD 123) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: SD 123) |
| 103TC0700X Psychologist Clinical (Licence: SD 123) | |
| 103TF0000X Psychologist Family (Licence: SD 123) | |
| 103TF0200X Psychologist Forensic (Licence: SD 123) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: SD 123) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: SD 123) | |
| 103TR0400X Psychologist Rehabilitation (Licence: SD 123) | |
| 103TS0200X Psychologist School (Licence: SD 29664-02) | |
| Enumeration Date | 2007-12-20 |
| Last Update Date | 2007-12-20 |