| NPI | 1124022736 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KS LP0648) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MO PYR0251) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2012-08-01 |