| NPI | 1578964979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: GA 4000) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: FL 17) |
| 103T00000X Psychologist (Licence: PA 18978) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2014-09-05 |
| Last Update Date | 2023-09-08 |