| NPI | 1972663839 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: ID PSY-194) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CO 944) |
| Enumeration Date | 2006-12-11 |
| Last Update Date | 2007-07-08 |