| NPI | 1265469282 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 261QV0200X Clinic/Center VA (Licence: MA 3881) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 3881) |
| 103TF0000X Psychologist Family (Licence: MA 3881) | |
| Enumeration Date | 2006-06-26 |
| Last Update Date | 2017-04-19 |