| NPI | 1710981477 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 31285) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: TX 31285) |
| Enumeration Date | 2005-06-10 |
| Last Update Date | 2011-12-10 |