| NPI | 1710540992 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CO PSY.0006904) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: CO 0015217) |
| Enumeration Date | 2019-04-15 |
| Last Update Date | 2025-10-01 |