| NPI | 1205593332 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NC 103414) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 103414) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 103414) | |
| Enumeration Date | 2021-11-23 |
| Last Update Date | 2022-02-21 |