| NPI | 1376691964 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301009431) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301009431) |
| 103TC0700X Psychologist Clinical (Licence: MI 6301009431) | |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2023-09-19 |