| NPI | 1174852628 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CA PSY14606) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301010562) |
| 103TC0700X Psychologist Clinical (Licence: MA 7511) | |
| Enumeration Date | 2009-12-11 |
| Last Update Date | 2016-04-30 |