| NPI | 1295783140 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 076608) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MN LP2220) |
| Enumeration Date | 2006-05-04 |
| Last Update Date | 2023-02-09 |