| NPI | 1518210079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: PA PS019677) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: TN 3295) |
| 103TC0700X Psychologist, Clinical (Licence: MA 9642) | |
| Enumeration Date | 2012-10-22 |
| Last Update Date | 2022-11-15 |