| NPI | 1336362516 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NY 68 017699) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: GA PSY001800) |
| Enumeration Date | 2007-04-10 |
| Last Update Date | 2014-04-29 |