| NPI | 1760506190 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist, Counseling (Licence: NM 1330) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: NC 3340) |
| 103TP0016X Psychologist, Prescribing (Medical) (Licence: NM 0054C) | |
| Enumeration Date | 2007-03-19 |
| Last Update Date | 2016-05-09 |