| NPI | 1235796004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: GA PSY004540) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: NE 11864) |
| Enumeration Date | 2019-05-28 |
| Last Update Date | 2021-09-16 |