| NPI | 1164616561 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 5070) |
| Additional Taxonomies | 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: MA 5070) |
| Enumeration Date | 2007-08-29 |
| Last Update Date | 2012-03-27 |