| NPI | 1508841727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 30742) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: TX 30742) |
| Enumeration Date | 2005-12-09 |
| Last Update Date | 2007-07-08 |