| NPI | 1740629328 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101Y00000X Counselor (Licence: FL IMH1504) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: FL IMH1504) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: FL IMH1504) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: FL IMH1504) | |
| Enumeration Date | 2013-06-18 |
| Last Update Date | 2013-06-18 |