| NPI | 1629765722 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: AZ 003910) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MI 6301019264) |
| 103TC0700X Psychologist, Clinical (Licence: WI 2612-57) | |
| Enumeration Date | 2023-04-19 |
| Last Update Date | 2023-04-19 |