| NPI | 1275150021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 11740) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: PA PS018773) |
| Enumeration Date | 2020-06-28 |
| Last Update Date | 2022-03-07 |