| NPI | 1609087816 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103TB0200X Psychologist Cognitive & Behavioral (Licence: MD 02179) |
| Additional Taxonomies | 103TC2200X Psychologist Clinical Child & Adolescent (Licence: MD 02179) |
| Enumeration Date | 2007-05-28 |
| Last Update Date | 2007-07-08 |