| NPI | 1609860881 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 103TC2200X Psychologist, Clinical Child & Adolescent (Licence: MA PY 2853 PR) |
| Additional Taxonomies | 103T00000X Psychologist (Licence: MA PY 2853 PR) |
| 103TS0200X Psychologist, School (Licence: MA 0139977 75Q) | |
| Enumeration Date | 2005-09-02 |
| Last Update Date | 2007-07-08 |