| NPI | 1083007322 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0804X Psychiatry & Neurology, Child & Adolescent Psychiatry (Licence: MN 71732) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2015-03-11 |
| Last Update Date | 2022-08-09 |