| NPI | 1629159140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: ID PSY-305) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: ID LCPC-144) |
| Enumeration Date | 2006-10-18 |
| Last Update Date | 2007-07-08 |