| NPI | 1780060004 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MO 2017039912) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KS 2557) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-08-10 |
| Last Update Date | 2018-03-17 |