| NPI | 1730879263 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MO 2025040316) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: TX 39854) |
| Enumeration Date | 2023-05-09 |
| Last Update Date | 2026-02-04 |