| NPI | 1679853568 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TB0200X Psychologist Cognitive & Behavioral (Licence: KY 1697) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: KY 129457) |
| 103TC0700X Psychologist Clinical (Licence: KY 1697) | |
| Enumeration Date | 2011-08-23 |
| Last Update Date | 2020-04-22 |