| NPI | 1700974540 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 129056) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: KY 167029) |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2023-05-27 |