| NPI | 1750503223 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: GA 2181) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MN LP4368) |
| 103TC0700X Psychologist, Clinical (Licence: FL 5546) | |
| 103TF0200X Psychologist, Forensic (Licence: FL 5546) | |
| 103TF0200X Psychologist, Forensic (Licence: NM 703) | |
| 103TF0200X Psychologist, Forensic (Licence: CO 2094) | |
| Enumeration Date | 2007-05-03 |
| Last Update Date | 2007-07-08 |