| 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 |