| NPI | 1124673173 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 103TS0200X Psychologist, School |
| 103TC2200X Psychologist, Clinical Child & Adolescent | |
| Enumeration Date | 2019-08-06 |
| Last Update Date | 2024-12-12 |