| NPI | 1083969471 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA PSY5000304) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103TC0700X Psychologist, Clinical (Licence: CT 4711) | |
| 103TC0700X Psychologist, Clinical (Licence: NH EL32460) | |
| Enumeration Date | 2012-07-21 |
| Last Update Date | 2025-07-11 |