| NPI | 1811301419 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 2084P0804X Psychiatry & Neurology Child & Adolescent Psychiatry (Licence: GA 78332) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NY 63536) |
| Enumeration Date | 2014-06-12 |
| Last Update Date | 2020-06-02 |