| NPI | 1912265661 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MO R0260) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: KS 0476) |
| Enumeration Date | 2012-05-01 |
| Last Update Date | 2012-05-01 |