| NPI | 1558547794 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 174400000X Specialist (Licence: NC JT873203) |
| Additional Taxonomies | 101Y00000X Counselor |
| 103TF0200X Psychologist, Forensic (Licence: NC 27054) | |
| Enumeration Date | 2008-01-17 |
| Last Update Date | 2017-03-07 |