| NPI | 1033266671 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3750) |
| Additional Taxonomies | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MA 3750) |
| 103TC0700X Psychologist Clinical (Licence: MA 3750) | |
| 103TF0200X Psychologist Forensic (Licence: MA 3750) | |
| 103TH0100X Psychologist Health Service (Licence: MA 3750) | |
| Enumeration Date | 2007-01-05 |
| Last Update Date | 2007-07-08 |