| NPI | 1003854712 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OH 5809) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: KY 1243) |
| Enumeration Date | 2006-06-03 |
| Last Update Date | 2008-09-12 |