| NPI | 1174673263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OR 0609) |
| Additional Taxonomies | 103TM1800X Psychologist, Intellectual & Developmental Disabilities |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2007-07-08 |