| NPI | 1952518706 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: KS LP508) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MO R0070 (INACTIVE)) |
| Enumeration Date | 2007-05-17 |
| Last Update Date | 2007-07-08 |