| NPI | 1003167909 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: WI 3168) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: PA PS015414) |
| Enumeration Date | 2012-10-02 |
| Last Update Date | 2019-07-09 |