| NPI | 1457483927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301013742) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301009775) |
| Enumeration Date | 2007-03-11 |
| Last Update Date | 2008-10-27 |