| NPI | 1053457366 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3639) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 3639) |
| Enumeration Date | 2007-01-30 |
| Last Update Date | 2012-03-06 |