| NPI | 1912947979 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: TX 22143) |
| Additional Taxonomies | 103TA0700X Psychologist, Adult Development & Aging (Licence: TX 22143) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: TX 22143) | |
| Enumeration Date | 2006-06-07 |
| Last Update Date | 2007-12-07 |