| NPI | 1225445588 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301016943) |
| Additional Taxonomies | 247200000X Technician, Other |
| Enumeration Date | 2014-07-18 |
| Last Update Date | 2018-03-17 |