| NPI | 1114210846 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: VA 0810005148) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 020252) |
| Enumeration Date | 2011-05-27 |
| Last Update Date | 2015-08-05 |