| NPI | 1760803514 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OH 6960) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: KY 1667) |
| Enumeration Date | 2013-12-20 |
| Last Update Date | 2021-03-05 |