| NPI | 1588626808 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OH 3117) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 0877) |
| Enumeration Date | 2006-04-03 |
| Last Update Date | 2007-09-20 |