| NPI | 1760544381 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WY 555) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: MO 2001025456) |
| 103T00000X Psychologist (Licence: MO 2012041096) | |
| Enumeration Date | 2006-12-14 |
| Last Update Date | 2014-12-02 |