| NPI | 1821086398 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CO 2124) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: WY 695) |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CO 2124) | |
| 103TH0004X Psychologist Health (Licence: CO 2124) | |
| Enumeration Date | 2005-10-10 |
| Last Update Date | 2022-11-08 |