| NPI | 1528251774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WA PY60200533) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: WA MC60190842) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: WA PY 60200533) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: WA PY60200533) | |
| 103TF0000X Psychologist Family (Licence: WA PY60200533) | |
| Enumeration Date | 2007-08-21 |
| Last Update Date | 2011-06-29 |