| NPI | 1528789633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: PR 007404) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: FL TPPY2854) |
| Enumeration Date | 2022-09-07 |
| Last Update Date | 2024-10-30 |