| NPI | 1336781491 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 5582) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) |
| 103TS0200X Psychologist School (Licence: NC 1197954) | |
| Enumeration Date | 2019-10-10 |
| Last Update Date | 2021-05-04 |