| NPI | 1740847755 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MO 2019030582) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KS LP-789) |
| Enumeration Date | 2019-05-24 |
| Last Update Date | 2019-08-09 |