| NPI | 1609807502 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0700X Psychologist Adult Development & Aging (Licence: CA PSY5027) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: CA PSY5027) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CA PSY5027) | |
| 103TE1100X Psychologist Exercise & Sports (Licence: CA PSY5027) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: CA PSY5027) | |
| 305R00000X Preferred Provider Organization (Licence: CA PSY5027) | |
| Enumeration Date | 2006-07-06 |
| Last Update Date | 2007-07-08 |