| NPI | 1275025553 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling |
| 103TB0200X Psychologist, Cognitive & Behavioral | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities | |
| Enumeration Date | 2018-06-03 |
| Last Update Date | 2018-06-03 |