| NPI | 1750695862 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: OR 2515) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: OR 2515) |
| Enumeration Date | 2010-07-30 |
| Last Update Date | 2018-01-26 |