| NPI | 1487631727 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MA 4895) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MA 4895) |
| 103TC0700X Psychologist Clinical (Licence: MA 4895) | |
| Enumeration Date | 2005-12-28 |
| Last Update Date | 2012-11-15 |