| NPI | 1780016444 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA PSY003926) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health |
| Enumeration Date | 2013-08-05 |
| Last Update Date | 2015-08-11 |