| NPI | 1588745897 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: AZ 3719) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: AZ 3719) |
| 103TC1900X Psychologist Counseling (Licence: AZ 3719) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: AZ 3719) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: AZ 3719) | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: AZ 3719) | |
| 103TF0000X Psychologist Family (Licence: AZ 3719) | |
| Enumeration Date | 2006-10-17 |
| Last Update Date | 2007-07-08 |