| NPI | 1205914173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MO 2006036655) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MO 2001014823) |
| Enumeration Date | 2006-11-01 |
| Last Update Date | 2025-09-11 |