| NPI | 1053835785 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 08100055555) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NY 013429-1) |
| Enumeration Date | 2017-08-03 |
| Last Update Date | 2022-06-06 |