| NPI | 1285799965 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 2912) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 2912) |
| 103TF0000X Psychologist Family (Licence: MA 2912) | |
| 103TH0100X Psychologist Health Service (Licence: MA 2912) | |
| Enumeration Date | 2006-12-24 |
| Last Update Date | 2007-07-08 |