| NPI | 1912275835 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NY 022980) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: WA 60817307) |
| Enumeration Date | 2011-12-06 |
| Last Update Date | 2023-10-12 |