| NPI | 1679851075 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OR 2220) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: OR 2220) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: OR 2220) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: OR 2220) | |
| 103TF0000X Psychologist Family (Licence: OR 2220) | |
| 103TF0200X Psychologist Forensic (Licence: OR 2220) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: OR 2220) | |
| Enumeration Date | 2011-08-02 |
| Last Update Date | 2014-05-06 |