| NPI | 1962539486 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: AZ 3659) |
| Additional Taxonomies | 363LP0808X Nurse Practitioner, Psych/Mental Health (Licence: AZ 3497) |
| Enumeration Date | 2007-02-28 |
| Last Update Date | 2010-03-19 |