| 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 |