| NPI | 1538204854 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: CT 000822) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: NY 0060371) |
| Enumeration Date | 2007-02-21 |
| Last Update Date | 2007-07-08 |