| NPI | 1760461792 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: SC 1253) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MD 4058) |
| Enumeration Date | 2006-01-10 |
| Last Update Date | 2024-05-31 |