| NPI | 1205374857 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 11931) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: VA 0810006033) |
| 103TC0700X Psychologist, Clinical (Licence: CT 3792) | |
| Enumeration Date | 2017-02-03 |
| Last Update Date | 2022-10-14 |