| NPI | 1558367565 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: PA PS-003680-L) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: PA PS-003680-L) |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: PA PS-003680-L) | |
| 103TC0700X Psychologist Clinical (Licence: PA PS-003680-L) | |
| 103TC1900X Psychologist Counseling (Licence: PA PS-003680-L) | |
| 103TM1800X Psychologist Mental Retardation & Developmental Disabilities (Licence: PA PS-003680-L) | |
| Enumeration Date | 2005-06-23 |
| Last Update Date | 2017-01-17 |