| NPI | 1265520159 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: RI 410) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: RI 410) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: RI 410) | |
| Enumeration Date | 2006-10-10 |
| Last Update Date | 2020-06-26 |