| NPI | 1417440371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KS 2883) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) |
| 101YP2500X Counselor Professional (Licence: KS 3260) | |
| Enumeration Date | 2018-06-14 |
| Last Update Date | 2020-12-07 |