| NPI | 1376648162 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: GA 1742) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: NY 5171) |
| Enumeration Date | 2006-09-14 |
| Last Update Date | 2007-07-08 |