| NPI | 1437209459 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: PA PS016988) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: DE 934) | |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2017-02-27 |