| NPI | 1841285079 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: FL PY3931) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: FL PA9101805) |
| Enumeration Date | 2005-09-14 |
| Last Update Date | 2022-01-18 |