| NPI | 1720593692 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WV 1164) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810005678) |
| Enumeration Date | 2017-12-13 |
| Last Update Date | 2018-03-13 |