| NPI | 1487943536 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 38749) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: RI PS01174) |
| Enumeration Date | 2011-03-29 |
| Last Update Date | 2022-06-01 |