| NPI | 1154676765 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810004620) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MD 04853) |
| Enumeration Date | 2012-07-19 |
| Last Update Date | 2012-10-05 |