| NPI | 1124115670 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WY 383) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: ND 149) |
| 103TC0700X Psychologist, Clinical (Licence: CO 2661) | |
| Enumeration Date | 2006-10-06 |
| Last Update Date | 2012-10-18 |