| NPI | 1780808741 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: OH 4311) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: KY 694) |
| Enumeration Date | 2007-04-12 |
| Last Update Date | 2007-07-08 |