| NPI | 1790727063 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: PA PS005055L) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: PA PS005055L) |
| Enumeration Date | 2006-06-12 |
| Last Update Date | 2012-02-02 |