| NPI | 1336118603 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP5024) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CA PSY12343) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2011-02-17 |