| NPI | 1457401564 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 8645) |
| Additional Taxonomies | 103TC0700X Psychologist, Clinical (Licence: MA 8645) |
| Enumeration Date | 2007-01-11 |
| Last Update Date | 2015-03-03 |