| NPI | 1831121821 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 8654) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA 5542) |
| Enumeration Date | 2006-07-07 |
| Last Update Date | 2025-09-11 |