| NPI | 1336353960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PR 3583) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: PR 204859) |
| Enumeration Date | 2007-05-10 |
| Last Update Date | 2010-03-18 |