| NPI | 1164872172 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 090735) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301016700) |
| Enumeration Date | 2016-06-21 |
| Last Update Date | 2019-01-08 |