NPI | 1255659918 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 36033) |
Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: GA PSY003356) |
Enumeration Date | 2010-05-05 |
Last Update Date | 2012-02-10 |