| NPI | 1801165147 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: IA 130726) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: IL 071.009770) |
| Enumeration Date | 2011-12-15 |
| Last Update Date | 2025-04-28 |