| NPI | 1669665923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 36906) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: WV 663) |
| Enumeration Date | 2007-08-21 |
| Last Update Date | 2019-01-28 |