| NPI | 1669933719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: AK 180102) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 7296) |
| 101YM0800X Counselor Mental Health | |
| Enumeration Date | 2019-03-29 |
| Last Update Date | 2024-06-17 |