| NPI | 1972692424 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: AZ LPC1772) |
| Additional Taxonomies | 103TP2701X Psychologist Group Psychotherapy (Licence: AZ LISAC0023) |
| Enumeration Date | 2006-10-12 |
| Last Update Date | 2009-05-07 |