| NPI | 1174593412 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810002252) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MD 0003150) |
| Enumeration Date | 2006-01-26 |
| Last Update Date | 2020-02-04 |