| NPI | 1679094718 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6351000653) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MI 6301018190) |
| Enumeration Date | 2017-06-28 |
| Last Update Date | 2020-06-01 |