| NPI | 1619020534 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: PA Ps-005765-L) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: VT 047-0000681) |
| Enumeration Date | 2007-01-22 |
| Last Update Date | 2007-07-08 |