| NPI | 1578153458 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VT 047.0133686) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: VT 047.0133686) |
| 101YA0400X Counselor Addiction (Substance Use Disorder) (Licence: VT 047.0133686) | |
| Enumeration Date | 2021-01-25 |
| Last Update Date | 2024-01-22 |