| NPI | 1205174679 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WA 1613) |
| Additional Taxonomies | 103TF0200X Psychologist Forensic (Licence: WA 1613) |
| Enumeration Date | 2013-01-19 |
| Last Update Date | 2013-01-19 |