| NPI | 1417205774 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA PS017720) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: TX 38201) |
| Enumeration Date | 2012-08-16 |
| Last Update Date | 2020-02-18 |