| NPI | 1760460687 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NC 3774) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MO 2007030010) |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: NC 1405) | |
| Enumeration Date | 2006-01-03 |
| Last Update Date | 2009-08-21 |