| NPI | 1083681696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TB0200X Psychologist Cognitive & Behavioral (Licence: KY 128152) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: KY 128152) |
| Enumeration Date | 2006-03-02 |
| Last Update Date | 2021-02-15 |