| NPI | 1386318830 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MO 2022009735) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MO 2011032619) |
| 101YP2500X Counselor, Professional (Licence: MO 2011032619) | |
| Enumeration Date | 2021-08-06 |
| Last Update Date | 2025-04-07 |