| NPI | 1114656766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: KS 03137) |
| 103TC1900X Psychologist, Counseling (Licence: MO 2022040767) | |
| 103TE1100X Psychologist, Exercise & Sports | |
| Enumeration Date | 2022-06-08 |
| Last Update Date | 2023-10-13 |