| NPI | 1902415342 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: WA PY61194044) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: NE 12174) |
| 103TC0700X Psychologist Clinical (Licence: WA PY61194044) | |
| Enumeration Date | 2020-07-30 |
| Last Update Date | 2022-12-20 |