| NPI | 1568624799 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TC0700X Psychologist, Clinical (Licence: NY 17930) |
| Additional Taxonomies | 390200000X Student in an Organized Health Care Education/Training Program (Licence: NJ 073836) |
| Enumeration Date | 2008-06-29 |
| Last Update Date | 2008-12-18 |