| NPI | 1861704207 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IL 071.008824) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: IL 180.008104) |
| 101YP2500X Counselor Professional (Licence: IL 178.006435) | |
| Enumeration Date | 2010-07-13 |
| Last Update Date | 2020-05-05 |