| NPI | 1982769204 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: OR 2649) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MA 10149) |
| 103TA0700X Psychologist, Adult Development & Aging (Licence: MA 10149) | |
| Enumeration Date | 2006-12-27 |
| Last Update Date | 2024-03-07 |