| NPI | 1205072766 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PY7742) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: RI PS00345) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: FL PY7742) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: RI PS00345) | |
| Enumeration Date | 2009-01-05 |
| Last Update Date | 2009-01-05 |