| NPI | 1770505851 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 23489) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: TX 23489) |
| Enumeration Date | 2006-07-24 |
| Last Update Date | 2011-10-21 |