| NPI | 1962947168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CO 4553) |
| Additional Taxonomies | 101YM0800X Counselor Mental Health (Licence: MA 10988) |
| 103TA0700X Psychologist Adult Development & Aging (Licence: CO 4553) | |
| 103TH0004X Psychologist Health (Licence: CO 4553) | |
| Enumeration Date | 2016-12-23 |
| Last Update Date | 2019-04-17 |