| NPI | 1265438022 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP1383) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: WI 1673) |
| Enumeration Date | 2005-06-24 |
| Last Update Date | 2009-09-11 |