| NPI | 1891890117 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: WY 574) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: UT 303824-2501) |
| Enumeration Date | 2006-09-13 |
| Last Update Date | 2016-08-24 |