| NPI | 1508073834 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WY 121) |
| Additional Taxonomies | 364SP0808X Clinical Nurse Specialist, Psych/Mental Health (Licence: WY 19300.0242) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2007-07-08 |