| NPI | 1609490234 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301018412) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810005570) |
| Enumeration Date | 2020-05-29 |
| Last Update Date | 2020-06-17 |