| NPI | 1457585614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WI 3638-57) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: WI 14358-130) |
| Enumeration Date | 2009-05-04 |
| Last Update Date | 2020-10-14 |