| NPI | 1770077059 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810007712) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: CO PSY.0004790) |
| Enumeration Date | 2018-06-19 |
| Last Update Date | 2022-10-17 |