| NPI | 1255863437 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NC 5157) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 23199) | |
| Enumeration Date | 2017-03-28 |
| Last Update Date | 2022-03-14 |