| NPI | 1639627763 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 5490) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 103TC0700X Psychologist Clinical (Licence: TN 4064) | |
| Enumeration Date | 2016-09-19 |
| Last Update Date | 2024-08-29 |