| NPI | 1154319655 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: FL PY6534) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: FL PY6534) |
| 103TC1900X Psychologist Counseling (Licence: FL PY6534) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: FL PY6534) | |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2021-05-18 |