| NPI | 1962251991 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 290577) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: KY 290577) |
| Enumeration Date | 2024-05-13 |
| Last Update Date | 2025-09-30 |