| NPI | 1689892291 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: AL 2116) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 4612890) |
| 103TC0700X Psychologist Clinical (Licence: VA 0810001021) | |
| 103TC0700X Psychologist Clinical (Licence: NC 4479) | |
| Enumeration Date | 2007-04-22 |
| Last Update Date | 2019-04-03 |