| NPI | 1932621034 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CA 35056) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CO PSY.0006386) |
| 103TF0200X Psychologist Forensic (Licence: CA 35056) | |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2017-07-10 |
| Last Update Date | 2025-05-07 |