| NPI | 1609960327 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 103T00000X Psychologist (Licence: CT 749) |
| Additional Taxonomies | 103TC0700X Psychologist Clinical (Licence: CT 749) |
| 103K00000X Behavior Analyst (Licence: CT 749) | |
| 103TB0200X Psychologist Cognitive & Behavioral (Licence: CT 749) | |
| 103TC2200X Psychologist Clinical Child & Adolescent (Licence: CT 749) | |
| 103TF0200X Psychologist Forensic (Licence: CT 749) | |
| 103TA0400X Psychologist Addiction (Substance Use Disorder) (Licence: CT 749) | |
| Enumeration Date | 2006-10-03 |
| Last Update Date | 2013-02-27 |