| NPI | 1215239801 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 1344) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: KY 1344) |
| 103T00000X Psychologist (Licence: KY 1344) | |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: KY 1344) | |
| 103TC1900X Psychologist, Counseling (Licence: KY 1344) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: KY 1344) | |
| Enumeration Date | 2010-12-02 |
| Last Update Date | 2012-10-04 |