| NPI | 1043617962 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP5801) | 
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: GA PSY004835) | 
| Enumeration Date | 2014-11-20 | 
| Last Update Date | 2025-03-27 |