| NPI | 1679509392 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CO PSY.0005215) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301010784) |
| Enumeration Date | 2006-06-24 |
| Last Update Date | 2021-02-09 |