| NPI | 1104596584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TS0200X Psychologist, School (Licence: WI 3001024492) |
| Additional Taxonomies | 103TS0200X Psychologist, School (Licence: OR 546227) |
| Enumeration Date | 2021-09-16 |
| Last Update Date | 2021-09-16 |