| NPI | 1568745925 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CA 25578) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 103TC0700X Psychologist, Clinical (Licence: MA 9539) | |
| 101YM0800X Counselor, Mental Health (Licence: MA 9539) | |
| Enumeration Date | 2011-09-22 |
| Last Update Date | 2013-04-02 |