| NPI | 1962615252 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 101YM0800X Counselor, Mental Health (Licence: DE PC-0000439)  | 
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: PA PS-006161-L)  | 
| 103TC1900X Psychologist, Counseling (Licence: PA PS-006161-L)  | |
| Enumeration Date | 2007-05-07 | 
| Last Update Date | 2018-08-01 |