| NPI | 1982988259 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MN LP6146) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: DC PSY1000841) |
| 103TC0700X Psychologist, Clinical (Licence: MD 05040) | |
| Enumeration Date | 2011-10-05 |
| Last Update Date | 2022-07-23 |