| NPI | 1205210127 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: ME PS1573) |
| Additional Taxonomies | 103T00000X Psychologist |
| 103TC0700X Psychologist Clinical (Licence: MD 05949) | |
| Enumeration Date | 2015-07-10 |
| Last Update Date | 2024-08-23 |