| NPI | 1801924782 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP5442) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: OH 6243) |
| Enumeration Date | 2007-03-01 |
| Last Update Date | 2021-12-29 |