| NPI | 1639232358 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: GA PSY001955) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: GA PSY001955) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: GA PSY001955) | |
| 103TH0100X Psychologist Health Service (Licence: GA PSY001955) | |
| Enumeration Date | 2006-12-18 |
| Last Update Date | 2013-10-11 |