| NPI | 1679631758 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NC 1924) |
| Additional Taxonomies | 103TA0700X Psychologist, Adult Development & Aging (Licence: NC 1924) |
| 103TB0200X Psychologist, Cognitive & Behavioral (Licence: NC 1924) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NC 1924) | |
| 103TF0200X Psychologist, Forensic (Licence: NC 1924) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: NC 1924) | |
| Enumeration Date | 2006-12-04 |
| Last Update Date | 2007-09-27 |