| NPI | 1821183633 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 34587) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 7924) |
| 103TC0700X Psychologist, Clinical (Licence: GA 1329) | |
| Enumeration Date | 2006-10-04 |
| Last Update Date | 2011-06-30 |