| NPI | 1639189566 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810000862) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: SC 1025) |
| Enumeration Date | 2006-08-09 |
| Last Update Date | 2007-07-09 |