| NPI | 1639231293 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CO 3040) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: CO 3040) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CO 3040) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: CO 3040) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: CO 3040) | |
| Enumeration Date | 2006-12-13 |
| Last Update Date | 2012-05-21 |