| NPI | 1811169261 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: LA 886) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: LA 886) |
| 103TS0200X Psychologist, School (Licence: LA 886) | |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: LA 886) | |
| Enumeration Date | 2008-03-26 |
| Last Update Date | 2009-05-29 |