| NPI | 1356792584 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: MA 10476) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MA 10476) |
| 103TC0700X Psychologist, Clinical (Licence: MA TBD) | |
| Enumeration Date | 2016-06-29 |
| Last Update Date | 2020-09-02 |