NPI | 1609591858 |
---|---|
Entity Type | Individual |
Gender | Male |
Sole Proprietor ? | Yes |
Primary Taxonomy | 103T00000X Psychologist (Licence: TX 40234) |
Additional Taxonomies | 171000000X Military Health Care Provider |
Enumeration Date | 2022-10-10 |
Last Update Date | 2025-01-10 |