| NPI | 1811073455 |
|---|---|
| Entity Type | Individual |
| Gender | N/A |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: VT 0680000409) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: VT 000101) |
| Enumeration Date | 2006-10-27 |
| Last Update Date | 2007-07-08 |