| NPI | 1114915022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301003046) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301003046) |
| Enumeration Date | 2005-10-13 |
| Last Update Date | 2021-10-17 |