| NPI | 1023247012 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 38905) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: IA 001175) |
| Enumeration Date | 2009-07-10 |
| Last Update Date | 2023-12-05 |