| NPI | 1376755850 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MD 03589) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 2824) |
| Enumeration Date | 2007-05-04 |
| Last Update Date | 2009-08-18 |