| 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 |