| NPI | 1467490664 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810001914) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: VA 08100001914) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2015-07-01 |