| NPI | 1689158776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: ID PSY203043) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: ID LCPC3816) |
| Enumeration Date | 2018-09-24 |
| Last Update Date | 2018-11-16 |