| NPI | 1578965109 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OH 7603) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301016017) |
| Enumeration Date | 2014-09-26 |
| Last Update Date | 2022-07-21 |