| NPI | 1710102835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: LA 919) |
| Additional Taxonomies | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: LA 919) |
| 103TB0200X Psychologist, Cognitive & Behavioral | |
| Enumeration Date | 2007-04-16 |
| Last Update Date | 2011-10-24 |