| NPI | 1568575413 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 291199) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: KY 0767) |
| Enumeration Date | 2006-08-16 |
| Last Update Date | 2024-11-11 |