| NPI | 1164446605 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TF0200X Psychologist Forensic |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities | |
| 103TB0200X Psychologist Cognitive & Behavioral | |
| 103TC1900X Psychologist Counseling | |
| 103TC2200X Psychologist Clinical Child & Adolescent | |
| Enumeration Date | 2006-07-27 |
| Last Update Date | 2020-04-14 |