| NPI | 1083917843 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 001199) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: PA PS016854) |
| Enumeration Date | 2010-12-15 |
| Last Update Date | 2011-08-11 |