| NPI | 1609836626 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NC 1751) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 634) |
| 106H00000X Marriage & Family Therapist (Licence: NC 032) | |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2013-05-30 |