| NPI | 1730167966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 36115) |
| Additional Taxonomies | 103TH0100X Psychologist, Health Service (Licence: KS 1353) |
| Enumeration Date | 2006-01-06 |
| Last Update Date | 2012-05-30 |