| NPI | 1063594414 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 9104) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 9104) | |
| Enumeration Date | 2006-10-19 |
| Last Update Date | 2010-05-25 |