| NPI | 1629051776 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 1249) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: OR C0068) |
| 103G00000X Clinical Neuropsychologist (Licence: OR 1249) | |
| Enumeration Date | 2005-11-22 |
| Last Update Date | 2009-03-02 |