| NPI | 1255521787 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301015156) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301015156) |
| 103TC0700X Psychologist Clinical (Licence: NE PLP302) | |
| Enumeration Date | 2007-07-31 |
| Last Update Date | 2020-11-11 |