| NPI | 1396830634 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC1900X Psychologist Counseling (Licence: MA 4511) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: MA 4511) |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2011-04-08 |