| NPI | 1477543163 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 39877) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MO 2005015537) |
| Enumeration Date | 2005-10-25 |
| Last Update Date | 2025-06-13 |