| NPI | 1962471391 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: VA 0810003230) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: TX 21133) |
| Enumeration Date | 2006-03-17 |
| Last Update Date | 2019-02-21 |