| NPI | 1790901452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810004019) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MA 4023) |
| Enumeration Date | 2007-04-18 |
| Last Update Date | 2019-07-05 |