| NPI | 1942427737 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: TX 25204) |
| Additional Taxonomies | 103TF0200X Psychologist Forensic (Licence: TX 25204) |
| 103TP2701X Psychologist Group Psychotherapy (Licence: TX 25204) | |
| Enumeration Date | 2007-04-20 |
| Last Update Date | 2007-07-08 |