| NPI | 1225102023 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: WV 271) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: WV 00133) |
| Enumeration Date | 2006-11-20 |
| Last Update Date | 2007-07-08 |