| NPI | 1306853197 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 9033) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MA 5957) |
| Enumeration Date | 2006-08-02 |
| Last Update Date | 2010-03-11 |