| NPI | 1639566391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OR 2604) |
| Additional Taxonomies | 103G00000X Clinical Neuropsychologist (Licence: OR 2604) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: OR 2604) | |
| 103TF0000X Psychologist, Family (Licence: OR 2604) | |
| 103TP2701X Psychologist, Group Psychotherapy (Licence: OR 2604) | |
| Enumeration Date | 2015-04-21 |
| Last Update Date | 2022-07-21 |