| NPI | 1669465993 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: KY 129106) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KY 842) |
| Enumeration Date | 2005-08-23 |
| Last Update Date | 2023-04-09 |