| NPI | 1063519940 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 746) |
| Additional Taxonomies | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: OR 746) |
| Enumeration Date | 2006-09-20 |
| Last Update Date | 2007-07-08 |