| NPI | 1578929386 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: MA 3439) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: NH 259 INACTIVE) |
| Enumeration Date | 2016-01-08 |
| Last Update Date | 2016-01-08 |