| NPI | 1831756204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810009002) |
| Additional Taxonomies | 171000000X Military Health Care Provider |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2019-05-21 |
| Last Update Date | 2025-07-04 |