| NPI | 1215059332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 101YM0800X Counselor Mental Health (Licence: DE PC0000911) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: NJ 37PC00708500) |
| 101YM0800X Counselor Mental Health (Licence: MA 7934-MH-CC) | |
| 101YP2500X Counselor Professional (Licence: PA PC007573) | |
| 103TC1900X Psychologist Counseling | |
| 103TC2200X Psychologist Clinical Child & Adolescent | |
| Enumeration Date | 2007-04-06 |
| Last Update Date | 2022-04-14 |