| NPI | 1154209468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PPY405) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: FL PPY405) |
| 103TF0000X Psychologist Family (Licence: FL PPY405) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: FL PPY405) | |
| 103TA0700X Psychologist Adult Development & Aging (Licence: FL PPY405) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: FL PPY405) | |
| Enumeration Date | 2025-08-25 |
| Last Update Date | 2025-08-25 |