| NPI | 1396419891 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810008092) |
| Additional Taxonomies | 171000000X Military Health Care Provider (Licence: VA 0810008092) |
| Enumeration Date | 2021-08-06 |
| Last Update Date | 2024-08-16 |