| NPI | 1518996164 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: OH 2020) |
| Additional Taxonomies | 103TE1100X Psychologist Exercise & Sports (Licence: OH 2020) |
| 103T00000X Psychologist (Licence: OH 2020) | |
| Enumeration Date | 2006-07-03 |
| Last Update Date | 2011-09-30 |