| NPI | 1164567731 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103T00000X Psychologist (Licence: NC 1569) |
| Additional Taxonomies | 103TB0200X Psychologist Cognitive & Behavioral (Licence: NC 1569) |
| 103TC0700X Psychologist Clinical (Licence: NC 1569) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: NC 1569) | |
| 103TF0000X Psychologist Family (Licence: NC 1569) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: NC 1569) | |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2007-07-08 |