| NPI | 1114957222 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301002824) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MI 6301002824) |
| 103TF0200X Psychologist Forensic (Licence: MI 6301002824) | |
| Enumeration Date | 2006-07-04 |
| Last Update Date | 2007-08-20 |