| NPI | 1811218183 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MS 48843) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: LA 1396) |
| Enumeration Date | 2010-06-21 |
| Last Update Date | 2019-08-29 |