| NPI | 1487066973 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 301864) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: Unlicensed) |
| Enumeration Date | 2014-06-02 |
| Last Update Date | 2026-02-09 |