| NPI | 1457729790 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PR 6235) |
| Additional Taxonomies | 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: PR 796) |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: PR 6235) | |
| Enumeration Date | 2015-09-03 |
| Last Update Date | 2019-02-04 |