| NPI | 1720786031 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QM0855X Clinic/Center, Adolescent and Children Mental Health (Licence: AZ OTC13694) |
| Additional Taxonomies | 106H00000X Marriage & Family Therapist (Licence: AZ LMFT15837) |
| Enumeration Date | 2023-02-16 |
| Last Update Date | 2025-05-07 |