| NPI | 1124514369 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810007596) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 10855) |
| Enumeration Date | 2018-07-10 |
| Last Update Date | 2023-08-10 |