| NPI | 1679533673 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WI 2104-057) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: TX 3-1940) |
| 103TC0700X Psychologist, Clinical (Licence: VT 725) | |
| Enumeration Date | 2006-03-24 |
| Last Update Date | 2023-08-15 |