| NPI | 1255496113 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: NY 012744) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent |
| 103TF0200X Psychologist Forensic (Licence: NY 012744) | |
| Enumeration Date | 2006-12-22 |
| Last Update Date | 2014-12-02 |