| NPI | 1184607483 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA 1922) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: SC 625) |
| Enumeration Date | 2005-11-21 |
| Last Update Date | 2007-07-08 |