| NPI | 1164785119 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0400X Psychologist Addiction (Substance Use Disorder) |
| Additional Taxonomies | 103T00000X Psychologist |
| 103TB0200X Psychologist Cognitive & Behavioral | |
| 103TP2701X Psychologist Group Psychotherapy | |
| 103TR0400X Psychologist Rehabilitation | |
| Enumeration Date | 2012-06-23 |
| Last Update Date | 2012-06-23 |