| NPI | 1306947585 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VT 0480076771) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: TX 33541) |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2021-05-17 |