| NPI | 1356045777 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KY 299720) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: NE 13446) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-03-29 |
| Last Update Date | 2026-05-22 |