| NPI | 1548864960 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6361007912) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MI 6362009104) |
| Enumeration Date | 2020-11-25 |
| Last Update Date | 2023-10-25 |