| NPI | 1346815792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP8686) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: FL PY11126) |
| Enumeration Date | 2021-05-26 |
| Last Update Date | 2023-11-01 |