| NPI | 1003957994 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: SD 274) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: SD 274) |
| 103T00000X Psychologist (Licence: SD 274) | |
| 103TS0200X Psychologist School (Licence: SD 274) | |
| Enumeration Date | 2007-02-12 |
| Last Update Date | 2007-07-08 |