| NPI | 1245465558 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP6424) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: KS LP 1925) |
| 103TC0700X Psychologist Clinical (Licence: MO 2014023517) | |
| Enumeration Date | 2009-05-16 |
| Last Update Date | 2021-08-24 |