| NPI | 1033731146 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PY10370) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810003528) |
| Enumeration Date | 2020-05-12 |
| Last Update Date | 2020-05-12 |