| NPI | 1538659867 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301018743) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 024845) |
| Enumeration Date | 2018-05-11 |
| Last Update Date | 2022-09-11 |