| NPI | 1023010691 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CO 2129) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: CO 2129) |
| Enumeration Date | 2005-08-12 |
| Last Update Date | 2009-06-11 |