| NPI | 1760693956 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MI 6301011692) |
| Additional Taxonomies | 103TS0200X Psychologist School (Licence: MI 6301011692) |
| Enumeration Date | 2007-05-27 |
| Last Update Date | 2007-07-09 |