| NPI | 1174979231 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 39255) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103T00000X Psychologist (Licence: TX 39255) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-05-09 |
| Last Update Date | 2022-09-23 |