| NPI | 1164461471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: SC 843) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NC 5119) |
| Enumeration Date | 2006-06-05 |
| Last Update Date | 2017-01-27 |