| NPI | 1629062682 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TN P856) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810002848) |
| Enumeration Date | 2005-09-07 |
| Last Update Date | 2007-07-08 |