| NPI | 1295040988 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WI 2962-57) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: WI 4444-125) |
| 101YM0800X Counselor Mental Health (Licence: WI 594-226) | |
| Enumeration Date | 2010-08-18 |
| Last Update Date | 2013-04-10 |