| NPI | 1124175302 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 8444) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 8444) |
| 103T00000X Psychologist (Licence: MA 8444) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MA 8444) | |
| Enumeration Date | 2007-01-03 |
| Last Update Date | 2007-07-08 |