| NPI | 1578841680 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MO 2013006410) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: KS 2170) |
| 101YM0800X Counselor, Mental Health (Licence: NE 9435) | |
| Enumeration Date | 2011-07-25 |
| Last Update Date | 2026-03-26 |