| NPI | 1376873729 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 15288) |
| Additional Taxonomies | 103TF0200X Psychologist Forensic |
| 103T00000X Psychologist (Licence: TX 15288) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: TX 15288) | |
| Enumeration Date | 2010-01-07 |
| Last Update Date | 2024-01-23 |