| NPI | 1003855024 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 38739) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: OR 1292) |
| 103TR0400X Psychologist, Rehabilitation (Licence: OR 1292) | |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2021-04-07 |