| NPI | 1205380508 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: PA PS018177) |
| Additional Taxonomies | 103TP2701X Psychologist Group Psychotherapy (Licence: PA PS018177) |
| 103TF0200X Psychologist Forensic (Licence: PA PS018177) | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: PA PS018177) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: PA PS018177) | |
| 103TC1900X Psychologist Counseling (Licence: PA PS018177) | |
| Enumeration Date | 2016-08-04 |
| Last Update Date | 2016-11-09 |