| NPI | 1356690689 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: KS 2318) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: KS 572) |
| Enumeration Date | 2012-08-31 |
| Last Update Date | 2022-10-26 |