| NPI | 1427437110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WA PY60334956) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: OR 2300-INACTIVE STATUS) |
| Enumeration Date | 2015-05-27 |
| Last Update Date | 2022-05-05 |