| NPI | 1508996992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA PS016418) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: PA PC002152) |
| Enumeration Date | 2007-03-06 |
| Last Update Date | 2008-05-15 |