| NPI | 1639297344 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | Yes | 
| Primary Taxonomy | 103T00000X Psychologist (Licence: VT 048.0135139) | 
| Additional Taxonomies | 103T00000X Psychologist (Licence: UT 5729247-2501) | 
| Enumeration Date | 2007-03-27 | 
| Last Update Date | 2025-06-07 |