| NPI | 1508131673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810001582) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MD 02207) |
| Enumeration Date | 2012-03-21 |
| Last Update Date | 2013-01-25 |