| NPI | 1760554034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: AZ 4253) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 2949) |
| Enumeration Date | 2006-11-14 |
| Last Update Date | 2018-09-19 |