| NPI | 1629019302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA 1917) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CA PSY10445) |
| Enumeration Date | 2006-06-10 |
| Last Update Date | 2007-07-08 |