| NPI | 1184039364 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TA0400X Psychologist, Addiction (Substance Use Disorder) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-06-25 |
| Last Update Date | 2018-03-17 |