| NPI | 1417111568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: TX 36046) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MO 2007012472) |
| Enumeration Date | 2008-07-17 |
| Last Update Date | 2021-11-04 |