| NPI | 1730301912 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: GA 1366) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: GA 1366) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: GA 1366) | |
| 103TF0000X Psychologist, Family (Licence: GA 1366) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: GA 1366) | |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2007-07-09 |