| NPI | 1912476094 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301017796) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: FL PY10241) |
| Enumeration Date | 2018-11-18 |
| Last Update Date | 2023-09-05 |