| NPI | 1417675067 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810007914) |
| Additional Taxonomies | 103TE1100X Psychologist, Exercise & Sports (Licence: MD 06569) |
| 103TE1100X Psychologist, Exercise & Sports (Licence: VA 0810007914) | |
| 103TC0700X Psychologist, Clinical (Licence: MD 06569) | |
| Enumeration Date | 2022-08-19 |
| Last Update Date | 2026-01-20 |