| NPI | 1811916588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: VA 0810002221) |
| Additional Taxonomies | 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: VA 0810002221) |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: VA 0810002221) | |
| 103TC0700X Psychologist, Clinical (Licence: VA 0810002221) | |
| 103T00000X Psychologist (Licence: VA 0810002221) | |
| Enumeration Date | 2006-07-19 |
| Last Update Date | 2007-07-09 |