| NPI | 1871078956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: FL PY9011) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: FL MCAP100418) |
| Enumeration Date | 2018-09-25 |
| Last Update Date | 2018-09-25 |