| NPI | 1659511194 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301017096) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: PA PS018057) |
| Enumeration Date | 2009-02-24 |
| Last Update Date | 2021-03-29 |