| NPI | 1952651804 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: UT 11316073-2501) |
| Additional Taxonomies | 101YA0400X Counselor, Addiction (Substance Use Disorder) |
| 103T00000X Psychologist | |
| Enumeration Date | 2012-09-18 |
| Last Update Date | 2020-12-23 |