| NPI | 1255693115 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: WI 3406) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: WI 3406) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-06-15 |
| Last Update Date | 2017-10-18 |