| NPI | 1619384815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301006993) |
| Additional Taxonomies | 103TS0200X Psychologist School (Licence: MI CC-0C3110345997) |
| Enumeration Date | 2014-07-20 |
| Last Update Date | 2014-08-09 |