| NPI | 1508117177 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MO 2012012270) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MO 2012012770) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MO 2012012770) | |
| Enumeration Date | 2012-09-24 |
| Last Update Date | 2020-12-24 |