| NPI | 1982682910 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NC 2789) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NC 2789) |
| 101YM0800X Counselor, Mental Health (Licence: NC 2789) | |
| Enumeration Date | 2006-01-09 |
| Last Update Date | 2013-11-01 |