| 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 |