| NPI | 1245993120 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP7050) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810006350) |
| Enumeration Date | 2021-10-18 |
| Last Update Date | 2025-11-01 |