| NPI | 1821217118 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: OR 1717) |
| Additional Taxonomies | 103TC1900X Psychologist, Counseling (Licence: OR 1717) |
| 103TE1100X Psychologist, Exercise & Sports (Licence: OR 1717) | |
| Enumeration Date | 2007-04-24 |
| Last Update Date | 2007-07-08 |