| NPI | 1396735395 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PR 1272) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: PR 1272) |
| 103TF0000X Psychologist Family (Licence: PR 1272) | |
| Enumeration Date | 2005-10-21 |
| Last Update Date | 2020-04-14 |