| NPI | 1760577340 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OH 4636) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: OH 4636) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2020-06-20 |