| NPI | 1053321208 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP0747) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: WI 1505-057) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2007-07-08 |