| NPI | 1508146424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: CO PSY.0003962) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103T00000X Psychologist (Licence: CO 0003962) | |
| 103T00000X Psychologist (Licence: CO 3962) | |
| Enumeration Date | 2011-08-23 |
| Last Update Date | 2022-08-01 |