| NPI | 1689763849 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WA 776) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: CO 2706) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2010-12-06 |