| NPI | 1245259514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 3239) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: TX 25370) |
| Enumeration Date | 2006-07-18 |
| Last Update Date | 2008-02-04 |