| NPI | 1679959738 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: WV 412) |
| Additional Taxonomies | 103TS0200X Psychologist, School (Licence: WV 22041) |
| Enumeration Date | 2015-07-30 |
| Last Update Date | 2015-07-30 |