| NPI | 1336217454 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP6039) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 019156) |
| 103TC0700X Psychologist, Clinical (Licence: MI 6301019263) | |
| Enumeration Date | 2006-11-30 |
| Last Update Date | 2023-09-06 |