| NPI | 1083920474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 4784) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MO 2011014431) |
| Enumeration Date | 2010-08-24 |
| Last Update Date | 2015-06-04 |