| NPI | 1720682602 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TS0200X Psychologist, School (Licence: MN 6480) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MN 6480) |
| Enumeration Date | 2020-11-23 |
| Last Update Date | 2020-11-23 |