| NPI | 1003189739 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: PA PS018815) |
| Additional Taxonomies | 222Q00000X Developmental Therapist |
| Enumeration Date | 2012-02-10 |
| Last Update Date | 2024-04-04 |