| NPI | 1114123452 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: FL PY 4415) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: FL Py 4415) |
| Enumeration Date | 2007-06-25 |
| Last Update Date | 2025-09-11 |