| NPI | 1003136409 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral |
| 103TC1900X Psychologist Counseling | |
| 103TC2200X Psychologist Clinical Child & Adolescent | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities | |
| 103TS0200X Psychologist School | |
| Enumeration Date | 2010-06-08 |
| Last Update Date | 2014-05-23 |