| NPI | 1104801620 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: UT 107339-2501) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: UT 221073392501) |
| Enumeration Date | 2005-12-07 |
| Last Update Date | 2022-04-13 |