| NPI | 1184112948 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TF0200X Psychologist Forensic (Licence: MA 9403) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CA 18566) |
| Enumeration Date | 2018-04-27 |
| Last Update Date | 2018-04-27 |