| NPI | 1902275365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: GA PSY004333) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NM PSY1721) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2015-09-16 |
| Last Update Date | 2022-06-24 |