| NPI | 1063832038 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CT 3379) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 007034) |
| Enumeration Date | 2014-04-17 |
| Last Update Date | 2019-02-13 |