| NPI | 1679511885 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP1964) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: WI 1024-057) |
| Enumeration Date | 2006-06-02 |
| Last Update Date | 2008-01-07 |