| NPI | 1942756242 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: TX 37345) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MI 6301014808) |
| 103TC0700X Psychologist Clinical (Licence: TX 37345) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: TX 37345) | |
| Enumeration Date | 2016-08-28 |
| Last Update Date | 2019-11-21 |