| NPI | 1306875612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 2105) |
| Additional Taxonomies | 103TA0700X Psychologist Adult Development & Aging (Licence: NC 2105) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: NC 2105) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 2105) | |
| 103TF0000X Psychologist Family (Licence: NC 2105) | |
| 103TH0100X Psychologist Health Service (Licence: NC 2105) | |
| Enumeration Date | 2006-06-30 |
| Last Update Date | 2021-01-17 |