| NPI | 1245688811 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 390200000X Student in an Organized Health Care Education/Training Program |
| Additional Taxonomies | 103T00000X Psychologist (Licence: OR 3002) |
| Enumeration Date | 2016-05-24 |
| Last Update Date | 2026-03-02 |