| NPI | 1184028896 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: CO 5536) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN 6579) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-10-09 |
| Last Update Date | 2021-07-25 |