| NPI | 1679921340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MN LP7072) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: WA MC60674058) |
| 103G00000X Clinical Neuropsychologist (Licence: ND 617) | |
| Enumeration Date | 2016-06-02 |
| Last Update Date | 2024-09-13 |