| NPI | 1629142054 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: IA 00913) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: IA 00913) |
| 103TC0700X Psychologist Clinical (Licence: IA 00913) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: IA 00913) | |
| 103TE1100X Psychologist Exercise & Sports (Licence: IA 00913) | |
| 103TF0000X Psychologist Family (Licence: IA 00913) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: IA 00913) | |
| Enumeration Date | 2006-11-18 |
| Last Update Date | 2019-10-17 |