| NPI | 1467702696 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP5893) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NY 019712) |
| Enumeration Date | 2012-09-14 |
| Last Update Date | 2020-08-24 |