| NPI | 1679636807 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OH 2620) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KY 298) |
| Enumeration Date | 2006-12-19 |
| Last Update Date | 2007-07-08 |