| NPI | 1003951765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810004723) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 3356) |
| Enumeration Date | 2007-02-20 |
| Last Update Date | 2013-05-16 |