| NPI | 1215608849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PR 7104) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: PR 7104) |
| Enumeration Date | 2021-09-23 |
| Last Update Date | 2021-09-23 |