| NPI | 1710798582 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: AZ PSY-T-000068) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: AZ PSY-T-000068) |
| Enumeration Date | 2025-01-20 |
| Last Update Date | 2025-06-16 |