| NPI | 1104008283 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: FL PY2886) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: GA PSY1989) |
| Enumeration Date | 2007-11-30 |
| Last Update Date | 2012-08-20 |