| NPI | 1740468115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 2106) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: NC 2106) |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: NC 2106) | |
| Enumeration Date | 2008-02-07 |
| Last Update Date | 2010-05-26 |