| NPI | 1700896453 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: SC 569) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: SC 569) |
| Enumeration Date | 2006-08-08 |
| Last Update Date | 2014-12-02 |