| NPI | 1780635193 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NC 3658) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: AR 055P) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 3658) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: AR 055P) | |
| 103TC0700X Psychologist Clinical (Licence: AR 055P) | |
| Enumeration Date | 2006-05-12 |
| Last Update Date | 2012-02-21 |