| NPI | 1295181196 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 39801) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: AZ 005356) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2016-05-10 |
| Last Update Date | 2023-03-27 |