| NPI | 1760480966 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MI 6301017038) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: TN P2573) |
| 103TF0000X Psychologist Family (Licence: MI 6301017038) | |
| Enumeration Date | 2005-07-12 |
| Last Update Date | 2017-06-09 |