| NPI | 1457700361 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: SD 292) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: SD 292) |
| 103TC1900X Psychologist Counseling (Licence: SD 292) | |
| Enumeration Date | 2016-06-10 |
| Last Update Date | 2016-06-18 |