| NPI | 1922109636 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301008585) |
| 103TS0200X Psychologist School | |
| Enumeration Date | 2006-09-26 |
| Last Update Date | 2012-01-19 |