| NPI | 1568992741 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 101YP2500X Counselor, Professional | |
| 103T00000X Psychologist | |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) | |
| Enumeration Date | 2017-06-19 |
| Last Update Date | 2022-08-09 |