| NPI | 1174725998 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: MA 8811) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 8811) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2007-06-04 |
| Last Update Date | 2018-06-05 |