| NPI | 1679029169 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: AK 144539) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: ID LPC-6613) |
| 101YM0800X Counselor, Mental Health (Licence: AK 137593) | |
| Enumeration Date | 2016-08-25 |
| Last Update Date | 2021-03-02 |