| NPI | 1811346950 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA PSY004334) |
| Additional Taxonomies | 101Y00000X Counselor |
| 103TC1900X Psychologist Counseling (Licence: GA PSY004334) | |
| Enumeration Date | 2016-06-09 |
| Last Update Date | 2020-06-25 |