| NPI | 1588969612 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP5709) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 018256) |
| Enumeration Date | 2011-01-20 |
| Last Update Date | 2022-06-09 |