| NPI | 1114130465 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: ID PSY 202479) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: CA 7790) |
| 103T00000X Psychologist (Licence: AZ 578) | |
| Enumeration Date | 2007-05-07 |
| Last Update Date | 2010-08-05 |