| NPI | 1609128404 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 36754) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810004671) |
| Enumeration Date | 2012-10-04 |
| Last Update Date | 2015-07-17 |