| NPI | 1336695162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WY 655) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: WY 655) |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2019-02-14 |