| NPI | 1639659642 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MO 2025043328) |
| Additional Taxonomies | 171M00000X Case Manager/Care Coordinator |
| Enumeration Date | 2018-08-19 |
| Last Update Date | 2025-10-23 |