| NPI | 1588642953 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TB0200X Psychologist Cognitive & Behavioral (Licence: WA PY2060) |
| Additional Taxonomies | 103TR0400X Psychologist Rehabilitation (Licence: OR 1287) |
| Enumeration Date | 2006-01-05 |
| Last Update Date | 2012-01-12 |