| NPI | 1497028872 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301006541) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301006541) |
| 103TA0700X Psychologist Adult Development & Aging (Licence: MI 6301006541) | |
| Enumeration Date | 2012-02-16 |
| Last Update Date | 2012-02-16 |