| NPI | 1730386772 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: KY 1062) |
| Additional Taxonomies | 103G00000X Clinical Neuropsychologist (Licence: KY 1062) |
| 103T00000X Psychologist (Licence: KY 1062) | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: KY 0385) | |
| Enumeration Date | 2007-07-02 |
| Last Update Date | 2012-10-16 |