| NPI | 1457491110 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP4284) |
| Additional Taxonomies | 103TF0200X Psychologist Forensic (Licence: MN LP4284) |
| Enumeration Date | 2007-02-08 |
| Last Update Date | 2007-10-23 |