| NPI | 1679623318 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 30903) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: TX 3-0903) |
| Enumeration Date | 2007-01-12 |
| Last Update Date | 2026-04-09 |