| NPI | 1609982040 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WI 1039-057) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: WI 12126) |
| Enumeration Date | 2006-08-21 |
| Last Update Date | 2008-06-30 |