| NPI | 1659700508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: WI 3501) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: WI 3501-57) |
| Enumeration Date | 2013-11-01 |
| Last Update Date | 2022-07-21 |