| NPI | 1134280365 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MA 4389) |
| Additional Taxonomies | 103TA0700X Psychologist Adult Development & Aging (Licence: MA 4389) |
| 103TC0700X Psychologist Clinical (Licence: MA 4389) | |
| 103T00000X Psychologist (Licence: MA 4389) | |
| Enumeration Date | 2006-12-12 |
| Last Update Date | 2007-07-08 |