| NPI | 1174712020 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 37379) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: CO 6320) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: TX 37379) | |
| 103TC0700X Psychologist, Clinical (Licence: CO 6320) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NY 020603) | |
| Enumeration Date | 2007-10-17 |
| Last Update Date | 2025-01-31 |