| NPI | 1225374309 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WY 567) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: WY WY567) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-12-18 |
| Last Update Date | 2021-04-15 |