| NPI | 1215128608 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301010839) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301010839) |
| Enumeration Date | 2007-08-09 |
| Last Update Date | 2015-07-22 |