| NPI | 1174514392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MD 04405) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 2608) |
| 103TH0100X Psychologist Health Service (Licence: MD 04405) | |
| Enumeration Date | 2005-11-04 |
| Last Update Date | 2008-01-23 |