| NPI | 1194412106 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NY 026812) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA PSY10001103) |
| 390200000X Student in an Organized Health Care Education/Training Program | |
| Enumeration Date | 2023-04-19 |
| Last Update Date | 2024-11-17 |