| NPI | 1538277058 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: CO 2857) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 005152) |
| 103TC1900X Psychologist, Counseling (Licence: AZ 4114) | |
| Enumeration Date | 2006-08-25 |
| Last Update Date | 2016-10-24 |