| NPI | 1538530472 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC0700X Psychologist Clinical (Licence: MA 9751) |
| Additional Taxonomies | 103TA0700X Psychologist Adult Development & Aging (Licence: MA 9751) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: MA 9751) | |
| 103TP2701X Psychologist Group Psychotherapy (Licence: MA 9751) | |
| Enumeration Date | 2015-10-19 |
| Last Update Date | 2015-10-19 |