| NPI | 1215097548 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 864) |
| Additional Taxonomies | 103TB0200X Psychologist, Cognitive & Behavioral (Licence: MA 864) |
| 103TF0000X Psychologist, Family (Licence: MA 864) | |
| 103TM1800X Psychologist, Intellectual & Developmental Disabilities (Licence: MA 864) | |
| Enumeration Date | 2006-12-08 |
| Last Update Date | 2012-05-02 |