| NPI | 1104104371 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KY 130762) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: KY 1533) |
| Enumeration Date | 2011-07-21 |
| Last Update Date | 2021-01-19 |