| NPI | 1275849614 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: SC PSY 1143) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: FL PY 5549) |
| Enumeration Date | 2010-08-24 |
| Last Update Date | 2011-03-15 |