| NPI | 1700884699 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: WV 603) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: WV 603) |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: WV 603) | |
| Enumeration Date | 2005-07-13 |
| Last Update Date | 2019-04-24 |