| NPI | 1780648014 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MO 2000166652) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MO 2000166652) |
| 103T00000X Psychologist (Licence: MO 2000166652) | |
| Enumeration Date | 2006-04-13 |
| Last Update Date | 2026-03-23 |