| NPI | 1104656248 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PY12222) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: PR 2612) |
| Enumeration Date | 2024-08-05 |
| Last Update Date | 2024-08-05 |