| NPI | 1336628056 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VT 048.0134205) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VT 151.0134063) |
| Enumeration Date | 2018-08-13 |
| Last Update Date | 2022-01-27 |