| NPI | 1750762670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CO PSY.0005640) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| 103K00000X Behavior Analyst | |
| Enumeration Date | 2015-06-16 |
| Last Update Date | 2021-11-11 |