| NPI | 1255634432 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301006643) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MI 6301006643) |
| Enumeration Date | 2010-12-10 |
| Last Update Date | 2010-12-10 |