| NPI | 1790763308 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NC 1169) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NC 1169) |
| 103TF0200X Psychologist Forensic (Licence: NC 1169) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: NC 1169) | |
| Enumeration Date | 2006-01-04 |
| Last Update Date | 2020-07-28 |