| NPI | 1861956815 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TS0200X Psychologist, School |
| Additional Taxonomies | 167G00000X Licensed Psychiatric Technician (Licence: CA PT30264) |
| Enumeration Date | 2019-01-23 |
| Last Update Date | 2021-10-14 |