| NPI | 1962499095 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: WA PY00000866) |
| Additional Taxonomies | 103TR0400X Psychologist Rehabilitation (Licence: WA PY00000866) |
| Enumeration Date | 2005-10-04 |
| Last Update Date | 2007-07-08 |