| NPI | 1528433877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TB0200X Psychologist, Cognitive & Behavioral |
| Additional Taxonomies | 261QM0801X Clinic/Center, Mental Health (Including Community Mental Health Center) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-12-10 |
| Last Update Date | 2018-04-12 |