| NPI | 1639193105 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KS 065) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: KS 137) |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2024-07-02 |