| NPI | 1841206091 | 
|---|---|
| Entity Type | Individual | 
| Gender | Male | 
| Sole Proprietor ? | No | 
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301013384) | 
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301013384) | 
| Enumeration Date | 2006-07-31 | 
| Last Update Date | 2025-07-09 |