| NPI | 1700059003 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 001244) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CT 002846) |
| Enumeration Date | 2008-04-08 |
| Last Update Date | 2020-10-15 |