| NPI | 1235404070 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PR 3500) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: PR 3500) |
| 103TF0000X Psychologist Family (Licence: PR 3500) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: PR 3500) | |
| Enumeration Date | 2012-03-13 |
| Last Update Date | 2012-03-13 |