| NPI | 1831170034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: KS 1264) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: MO 000245) |
| 103TC0700X Psychologist Clinical (Licence: MO 00324) | |
| 106H00000X Marriage & Family Therapist (Licence: MO 300028) | |
| Enumeration Date | 2005-11-07 |
| Last Update Date | 2024-02-08 |