| NPI | 1013455435 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 3165) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2017-02-06 |
| Last Update Date | 2020-04-13 |