| NPI | 1790769719 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MO 00368) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: MO 00368) |
| 103TH0100X Psychologist, Health Service (Licence: MO 00368) | |
| Enumeration Date | 2005-12-02 |
| Last Update Date | 2010-01-12 |