| NPI | 1053891929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301019767) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: WY 805) |
| Enumeration Date | 2018-08-20 |
| Last Update Date | 2026-04-29 |