| NPI | 1083835664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MD 04371) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810003351) |
| Enumeration Date | 2007-05-01 |
| Last Update Date | 2007-10-25 |