| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
|
| Primary Taxonomy | 103TR0400X Psychologist, Rehabilitation |
| Additional Taxonomies | 101Y00000X Counselor |
| 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 101YM0800X Counselor, Mental Health |
| 103T00000X Psychologist |
| 103TA0400X Psychologist, Addiction (Substance Use Disorder) |
| 103TB0200X Psychologist, Cognitive & Behavioral |
| 103TC1900X Psychologist, Counseling |
| 103TC2200X Psychologist, Clinical Child & Adolescent |
| 103TF0000X Psychologist, Family |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities |
| 103TP2701X Psychologist, Group Psychotherapy |
| Enumeration Date | 2018-09-14 |
| Last Update Date | 2018-09-14 |