| NPI | 1528552627 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: KY 130827) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: KY 130827) |
| Enumeration Date | 2018-06-21 |
| Last Update Date | 2022-12-07 |