| NPI | 1790155968 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: WA 61444148) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103G00000X Clinical Neuropsychologist | |
| 103T00000X Psychologist (Licence: KY 276359) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-10-01 |
| Last Update Date | 2024-06-17 |