| NPI | 1104871086 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CT 002812) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 016654-1) |
| Enumeration Date | 2006-05-23 |
| Last Update Date | 2009-05-06 |