| NPI | 1083768147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6301002855) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301002855) |
| Enumeration Date | 2007-01-23 |
| Last Update Date | 2007-07-08 |