| NPI | 1679976021 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MI 6361005155) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MI 6301014694) |
| Enumeration Date | 2014-09-30 |
| Last Update Date | 2024-10-17 |