| NPI | 1649604869 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: ND 523) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MN LP5937) |
| Enumeration Date | 2013-08-23 |
| Last Update Date | 2020-02-12 |