| NPI | 1619278769 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA PS017334) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810004328) |
| Enumeration Date | 2010-11-05 |
| Last Update Date | 2019-04-25 |