| NPI | 1124028543 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KY 00838) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: OH 5094) |
| 103TC0700X Psychologist, Clinical (Licence: KY 00838) | |
| Enumeration Date | 2005-07-28 |
| Last Update Date | 2019-06-05 |