| NPI | 1710187117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TH0100X Psychologist Health Service (Licence: NC 4568) |
| Additional Taxonomies | 103TH0100X Psychologist Health Service (Licence: MA 4900) |
| Enumeration Date | 2007-07-23 |
| Last Update Date | 2014-11-28 |