| NPI | 1518200039 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OR 2603) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CA 25546) |
| Enumeration Date | 2013-04-03 |
| Last Update Date | 2016-07-22 |