| NPI | 1548512577 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 4359) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 4359) |
| Enumeration Date | 2012-10-15 |
| Last Update Date | 2023-07-26 |