| NPI | 1831426949 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 1969) |
| Additional Taxonomies | 101Y00000X Counselor (Licence: OR 1969) |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) (Licence: OR 1969) | |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: OR 1969) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: OR 1969) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: OR 1969) | |
| Enumeration Date | 2009-11-10 |
| Last Update Date | 2009-11-10 |