| NPI | 1891212833 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810008601) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) (Licence: PA 9282) |
| 101YP2500X Counselor, Professional (Licence: PA PC009283) | |
| 103T00000X Psychologist | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-08-29 |
| Last Update Date | 2024-09-03 |