| NPI | 1609900471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MT MT # 378) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: KY KY367) |
| Enumeration Date | 2007-03-15 |
| Last Update Date | 2010-01-02 |