| NPI | 1295071546 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NE 930) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810005266) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2012-12-13 |
| Last Update Date | 2017-07-14 |