| NPI | 1043817489 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TE1100X Psychologist Exercise & Sports (Licence: MA 11360) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling (Licence: MA 11360) |
| Enumeration Date | 2020-10-08 |
| Last Update Date | 2020-10-08 |