| NPI | 1629125273 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WY 351) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810005771) |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2021-03-18 |