| NPI | 1154332039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: TX 37135) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: IA 001308) |
| Enumeration Date | 2006-08-10 |
| Last Update Date | 2021-02-25 |