| NPI | 1124185624 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 4167) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 4167) |
| 103TC1900X Psychologist Counseling (Licence: MA 4167) | |
| Enumeration Date | 2007-01-03 |
| Last Update Date | 2010-08-31 |