| NPI | 1134728421 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 38811) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810007266) |
| Enumeration Date | 2020-10-19 |
| Last Update Date | 2022-06-30 |