| NPI | 1528597929 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301018103) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301017640) |
| Enumeration Date | 2017-06-08 |
| Last Update Date | 2024-07-03 |