| NPI | 1215010681 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 7180) |
| Additional Taxonomies | 101YM0800X Counselor, Mental Health (Licence: MA 845) |
| 103T00000X Psychologist (Licence: MA 308) | |
| 103TS0200X Psychologist, School (Licence: MA 163046) | |
| Enumeration Date | 2006-10-21 |
| Last Update Date | 2023-06-28 |