| NPI | 1316361728 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CO PSY.0005752) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301015832) |
| 103TS0200X Psychologist, School (Licence: TX 71316) | |
| Enumeration Date | 2014-02-06 |
| Last Update Date | 2023-03-08 |