| NPI | 1497029607 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: FL PY10808) |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YM0800X Counselor, Mental Health (Licence: FL MH 14509) | |
| Enumeration Date | 2012-03-06 |
| Last Update Date | 2020-08-18 |