| NPI | 1740326446 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 101004055) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 101004055) |
| Enumeration Date | 2007-01-29 |
| Last Update Date | 2012-10-01 |