| NPI | 1275185472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: CO PSY.0006484) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NE 11915) |
| Enumeration Date | 2019-07-09 |
| Last Update Date | 2025-07-01 |