| NPI | 1164638417 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 1041C0700X Social Worker Clinical (Licence: CO 77) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CO 0003755) |
| Enumeration Date | 2007-05-15 |
| Last Update Date | 2020-12-03 |