| NPI | 1407153471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: FL PY9590) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 019192) |
| Enumeration Date | 2011-02-27 |
| Last Update Date | 2019-07-20 |