| NPI | 1124552963 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP6736) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 022351) |
| Enumeration Date | 2017-04-19 |
| Last Update Date | 2022-06-15 |