| 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, Intellectual & Developmental Disabilities (Licence: CO 3040) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: CO 3040) | |
| Enumeration Date | 2006-12-13 | 
| Last Update Date | 2012-05-21 |