| NPI | 1639131824 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MD 3117) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 5155) |
| 103TC0700X Psychologist, Clinical (Licence: MI 2967) | |
| Enumeration Date | 2006-04-04 |
| Last Update Date | 2007-07-12 |