| NPI | 1417351727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6361003953) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301015605) |
| Enumeration Date | 2014-10-15 |
| Last Update Date | 2020-04-30 |