| NPI | 1306933668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CO 856) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: WY 394) |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: WY 394) | |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: CO 856) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: WY 394) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: CO 856) | |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2009-01-21 |