| NPI | 1174395404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling (Licence: CA 35190) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: WY 796) |
| 103TE1100X Psychologist, Exercise & Sports | |
| Enumeration Date | 2023-10-30 |
| Last Update Date | 2024-08-22 |