| NPI | 1235255589 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: MA 7364) |
| Additional Taxonomies | 103TC1900X Psychologist Counseling |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 7364) | |
| Enumeration Date | 2007-03-21 |
| Last Update Date | 2007-07-08 |