| NPI | 1639166168 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KS LP03120) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MO R0201) |
| Enumeration Date | 2005-09-30 |
| Last Update Date | 2024-07-15 |