| NPI | 1417005554 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 1376) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: CT 464) |
| Enumeration Date | 2007-01-08 |
| Last Update Date | 2007-07-08 |