| NPI | 1730654401 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 39919) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CA 30387) |
| Enumeration Date | 2018-10-09 |
| Last Update Date | 2024-01-29 |