| NPI | 1104901172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NY 020658) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP2505) |
| 103TC0700X Psychologist, Clinical (Licence: MN LP2505) | |
| Enumeration Date | 2006-10-26 |
| Last Update Date | 2024-03-19 |