| NPI | 1407252604 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TP0016X Psychologist, Prescribing (Medical) (Licence: LA 300762) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: LA 1247) |
| 103TR0400X Psychologist, Rehabilitation (Licence: LA 1247) | |
| Enumeration Date | 2014-11-15 |
| Last Update Date | 2016-02-06 |