| NPI | 1366526212 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: OR 1801) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: OR 1801) | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: OR 1801) | |
| 103TH0004X Psychologist Health (Licence: OR 1801) | |
| Enumeration Date | 2006-10-25 |
| Last Update Date | 2007-11-01 |