| NPI | 1063882025 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CT 3667) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NY 022471) |
| 103T00000X Psychologist (Licence: MA 11025) | |
| Enumeration Date | 2015-10-03 |
| Last Update Date | 2024-05-14 |