| NPI | 1013436567 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 3027) | 
| Additional Taxonomies | 103T00000X Psychologist (Licence: FL PY9989) | 
| Enumeration Date | 2017-09-15 | 
| Last Update Date | 2025-08-18 |