| NPI | 1104224211 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PY9131) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: FL PY9131) |
| Enumeration Date | 2014-12-06 |
| Last Update Date | 2022-07-21 |