| NPI | 1992258560 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MI 6301017920) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MI 6301017268) |
| 390200000X Student in an Organized Health Care Education/Training Program (Licence: MI 6301015567) | |
| Enumeration Date | 2016-07-29 |
| Last Update Date | 2019-10-08 |