| NPI | 1679607717 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OR 743) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: WA 2803) |
| Enumeration Date | 2007-03-14 |
| Last Update Date | 2007-07-08 |