| NPI | 1992113690 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MD 05700) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| Enumeration Date | 2014-07-25 |
| Last Update Date | 2019-12-30 |