| NPI | 1629079835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OR 643) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CA PSY4779) |
| Enumeration Date | 2005-08-10 |
| Last Update Date | 2007-10-29 |