| NPI | 1568067668 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA 11295) |
| Additional Taxonomies | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: NC 5416) |
| 103TS0200X Psychologist, School (Licence: MA 506976) | |
| Enumeration Date | 2020-12-04 |
| Last Update Date | 2020-12-04 |