| NPI | 1285619502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA 2903) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: GA 2903) |
| 103TE1100X Psychologist Exercise & Sports (Licence: GA 2903) | |
| 103T00000X Psychologist (Licence: GA 2903) | |
| 103TR0400X Psychologist Rehabilitation (Licence: GA 2903) | |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2007-07-08 |