| NPI | 1154501062 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MI 6301013771) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301013771) |
| Enumeration Date | 2007-11-08 |
| Last Update Date | 2014-03-14 |