| NPI | 1609821768 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: AZ 0656) |
| Additional Taxonomies | 103TF0200X Psychologist Forensic (Licence: AZ 0656) |
| Enumeration Date | 2006-05-24 |
| Last Update Date | 2007-07-08 |