| NPI | 1679041875 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WV 1332) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: VA 0701010362) |
| 101YM0800X Counselor, Mental Health (Licence: WV 2389) | |
| Enumeration Date | 2018-11-06 |
| Last Update Date | 2023-08-02 |