| NPI | 1104887512 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: FL PY0003703) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: GA PSY001085) |
| 103TC0700X Psychologist, Clinical (Licence: AL 588) | |
| Enumeration Date | 2006-03-28 |
| Last Update Date | 2023-10-04 |