| NPI | 1619920980 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: SC 0575) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: NC 1973) |
| 101YM0800X Counselor Mental Health (Licence: SC 0575) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: SC 0575) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: NC 1973) | |
| 103TC0700X Psychologist Clinical (Licence: NC 1973) | |
| 103T00000X Psychologist (Licence: SC 0575) | |
| 103T00000X Psychologist (Licence: NC 1973) | |
| Enumeration Date | 2006-05-18 |
| Last Update Date | 2010-09-02 |