| NPI | 1417155953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 208000000X Pediatrics (Licence: KY 46857) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KY 1376) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-07-05 |
| Last Update Date | 2021-04-13 |