| NPI | 1184647976 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3733) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 3733) |
| 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 3733) | |
| Enumeration Date | 2006-07-25 |
| Last Update Date | 2007-07-09 |