| NPI | 1104916766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MS 52911) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MS 52911) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MS 52911) | |
| Enumeration Date | 2006-10-13 |
| Last Update Date | 2020-10-08 |