| NPI | 1609945468 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810-2452) |
| Additional Taxonomies | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: VA 0810-2452) |
| Enumeration Date | 2006-11-07 |
| Last Update Date | 2007-07-09 |