| NPI | 1104960061 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP4773) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP4773) |
| Enumeration Date | 2007-02-16 |
| Last Update Date | 2016-06-28 |