| NPI | 1043507759 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301016302) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MI 6301016302) |
| Enumeration Date | 2011-07-01 |
| Last Update Date | 2024-12-11 |