NPI | 1255463840 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810002770) |
Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: VA 0701002542) |
106H00000X Marriage & Family Therapist (Licence: VA 0717000627) | |
Enumeration Date | 2007-03-10 |
Last Update Date | 2022-02-08 |