| NPI | 1639590748 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TE1100X Psychologist, Exercise & Sports (Licence: CO 2922) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: CO 2922) |
| Enumeration Date | 2013-12-17 |
| Last Update Date | 2016-09-20 |