| NPI | 1912266750 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103K00000X Behavior Analyst (Licence: VA 1-01-0401) |
| Additional Taxonomies | 101YP2500X Counselor Professional (Licence: VA 0701000511) |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: VA 0811000982) | |
| Enumeration Date | 2012-05-14 |
| Last Update Date | 2012-05-14 |