| NPI | 1861110330 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810009160) |
| Additional Taxonomies | 101YP2500X Counselor, Professional (Licence: MD A0881) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2022-08-19 |
| Last Update Date | 2025-10-31 |