| NPI | 1114473923 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 11803) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health |
| 103TC0700X Psychologist, Clinical (Licence: MA 11803) | |
| Enumeration Date | 2016-08-31 |
| Last Update Date | 2020-07-08 |