| NPI | 1285708917 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NC 2092) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 1303) |
| Enumeration Date | 2006-11-17 |
| Last Update Date | 2025-10-27 |