| NPI | 1619570520 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: ME PS2052) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MA 10926) |
| Enumeration Date | 2020-11-21 |
| Last Update Date | 2021-12-28 |