| NPI | 1083953871 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WV 1069) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: ID PSY202726) |
| Enumeration Date | 2013-02-14 |
| Last Update Date | 2023-01-09 |