| NPI | 1720188840 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: LA 706) |
| Additional Taxonomies | 261QV0200X Clinic/Center, VA (Licence: LA 706) |
| Enumeration Date | 2006-09-25 |
| Last Update Date | 2017-04-02 |