| NPI | 1164987558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OR 3200) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MD 06011) |
| Enumeration Date | 2019-02-10 |
| Last Update Date | 2021-09-29 |