| NPI | 1104062942 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 4645) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 4645) |
| Enumeration Date | 2008-12-29 |
| Last Update Date | 2008-12-29 |