| NPI | 1174772578 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: WA 00003916) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: WA 00003916) |
| Enumeration Date | 2008-09-10 |
| Last Update Date | 2025-09-16 |