| NPI | 1225346935 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OR 2102) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: OR 16500000) |
| Enumeration Date | 2010-09-15 |
| Last Update Date | 2020-10-14 |