| NPI | 1205988474 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: AZ AZ3877) |
| Additional Taxonomies | 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: AZ 3877) |
| Enumeration Date | 2007-01-17 |
| Last Update Date | 2014-08-27 |