| NPI | 1205929924 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 2727) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: RI PS00678) |
| Enumeration Date | 2006-10-02 |
| Last Update Date | 2012-03-12 |