| NPI | 1902068927 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MN LP4574) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: VA 0810002468) |
| 103TC0700X Psychologist Clinical (Licence: VT 048-0000892) | |
| Enumeration Date | 2008-07-01 |
| Last Update Date | 2008-07-01 |