| NPI | 1790892685 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: UT 1104522501) |
| Additional Taxonomies | 1041C0700X Social Worker Clinical (Licence: UT 1104523501) |
| Enumeration Date | 2006-08-24 |
| Last Update Date | 2007-07-08 |