| NPI | 1124309877 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OR 2135) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: OR 2135) |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: OR 2135) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: OR 2135) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: OR 2135) | |
| Enumeration Date | 2011-09-07 |
| Last Update Date | 2011-09-07 |