| NPI | 1548365422 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WV 928) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810000219) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2012-11-14 |