| NPI | 1619932217 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301019465) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810003500) |
| Enumeration Date | 2006-04-18 |
| Last Update Date | 2025-06-30 |