| NPI | 1003384744 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: PR 7364) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: Process) |
| Enumeration Date | 2018-11-12 |
| Last Update Date | 2023-03-08 |